Healthcare Provider Details

I. General information

NPI: 1104697176
Provider Name (Legal Business Name): PNW IV HYDRATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23300 NW BRAVO RD
BUXTON OR
97109-9401
US

IV. Provider business mailing address

23300 NW BRAVO RD
BUXTON OR
97109-9401
US

V. Phone/Fax

Practice location:
  • Phone: 916-479-5235
  • Fax:
Mailing address:
  • Phone: 916-479-5235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: SANDRA CAROLINE GREENE
Title or Position: MEDICAL DIRECTOR
Credential: FNP-C
Phone: 916-271-7445