Healthcare Provider Details

I. General information

NPI: 1497669337
Provider Name (Legal Business Name): EDEN MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15455 NW GREENBRIER PKWY STE 200
BEAVERTON OR
97006-7359
US

IV. Provider business mailing address

11035 NE SANDY BLVD
PORTLAND OR
97220-2553
US

V. Phone/Fax

Practice location:
  • Phone: 503-258-4495
  • Fax:
Mailing address:
  • Phone: 503-258-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: