Healthcare Provider Details

I. General information

NPI: 1609587708
Provider Name (Legal Business Name): NORTHSTAR IOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16100 NW CORNELL RD STE 220B
BEAVERTON OR
97006-7334
US

IV. Provider business mailing address

16100 NW CORNELL RD STE 220B
BEAVERTON OR
97006-7334
US

V. Phone/Fax

Practice location:
  • Phone: 503-878-8885
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RYAN GLOCK
Title or Position: PARTNER
Credential:
Phone: 503-888-8050