Healthcare Provider Details

I. General information

NPI: 1477391878
Provider Name (Legal Business Name): JOSE LUIS DE LA TORRE JR. MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 E POWELL BLVD
GRESHAM OR
97030-8003
US

IV. Provider business mailing address

6200 SE KING RD
PORTLAND OR
97222-2891
US

V. Phone/Fax

Practice location:
  • Phone: 503-546-6377
  • Fax:
Mailing address:
  • Phone: 503-546-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number93-0841022
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number93-0841022
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: