Healthcare Provider Details

I. General information

NPI: 1306003645
Provider Name (Legal Business Name): RINNOVARE LASER AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23479 SE STARK ST
GRESHAM OR
97030-2962
US

IV. Provider business mailing address

23479 SE STARK ST
GRESHAM OR
97030-2962
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-9300
  • Fax: 503-667-4975
Mailing address:
  • Phone: 503-667-9300
  • Fax: 503-667-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3026
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number0932
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number23982
License Number StateOR

VIII. Authorized Official

Name: MS. HEIDI A WALTER
Title or Position: OFFICE MANAGER
Credential: CA
Phone: 503-667-9300