Healthcare Provider Details

I. General information

NPI: 1053287128
Provider Name (Legal Business Name): LOLO'S KITCHEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 SW COUNTRY CLUB DR
CORVALLIS OR
97333-1987
US

IV. Provider business mailing address

5441 S MACADAM AVE STE N
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-9703
  • Fax: 971-484-1958
Mailing address:
  • Phone: 503-535-9703
  • Fax: 971-484-1958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN TOBEY
Title or Position: EMPLOYEE
Credential: MS, RD, LD
Phone: 503-535-9703