Healthcare Provider Details

I. General information

NPI: 1497474993
Provider Name (Legal Business Name): REVIANCE PORTLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9280 SE SUNNYBROOK BLVD STE 301
CLACKAMAS OR
97015-9353
US

IV. Provider business mailing address

9280 SE SUNNYBROOK BLVD STE 301
CLACKAMAS OR
97015-9353
US

V. Phone/Fax

Practice location:
  • Phone: 503-953-1230
  • Fax:
Mailing address:
  • Phone: 503-953-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JAMES CHAN
Title or Position: OWNER
Credential: MD
Phone: 503-953-1230