Healthcare Provider Details

I. General information

NPI: 1205055100
Provider Name (Legal Business Name): MAUREEN MCCLENON SACON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

PO BOX 266
UNDERWOOD WA
98651-0266
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5555
  • Fax: 503-674-5005
Mailing address:
  • Phone: 503-491-5555
  • Fax: 503-674-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberDO20023
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: