Healthcare Provider Details

I. General information

NPI: 1952845547
Provider Name (Legal Business Name): SARA L O'LEARY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 SE SUNNYSIDE RD SUITE 224-S
CLACKAMAS OR
97015-5738
US

IV. Provider business mailing address

8800 SE SUNNYSIDE RD SUITE 224-S
CLACKAMAS OR
97015-5738
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-5070
  • Fax: 800-957-1067
Mailing address:
  • Phone: 503-652-5070
  • Fax: 800-957-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10177131
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI 60671055
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: