Healthcare Provider Details

I. General information

NPI: 1558526913
Provider Name (Legal Business Name): STEPHEN T ENSIGN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MOUNTAIN VIEW LANE SUITE 200
FOREST GROVE OR
97116-2382
US

IV. Provider business mailing address

1911 MOUNTAIN VIEW LANE SUITE 200
FOREST GROVE OR
97116-2382
US

V. Phone/Fax

Practice location:
  • Phone: 503-357-2826
  • Fax: 503-357-4831
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4188
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: