Healthcare Provider Details

I. General information

NPI: 1639793367
Provider Name (Legal Business Name): NORTHWEST GERIACTRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10365 SE SUNNYSIDE RD STE 340
CLACKAMAS OR
97015-5751
US

IV. Provider business mailing address

206 N 2100 W STE 202
SALT LAKE CITY UT
84116-4741
US

V. Phone/Fax

Practice location:
  • Phone: 143-586-2614
  • Fax:
Mailing address:
  • Phone: 435-862-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK L PHILLIPS
Title or Position: PRESIDENT
Credential: MBA/MHA
Phone: 435-862-6143