Healthcare Provider Details

I. General information

NPI: 1639352594
Provider Name (Legal Business Name): ROSE CITY BREAST CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR SUITE 301
GRESHAM OR
97030-3721
US

IV. Provider business mailing address

831 NW COUNCIL DR SUITE 301
GRESHAM OR
97030-3721
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-9700
  • Fax: 503-661-9800
Mailing address:
  • Phone: 503-661-9700
  • Fax: 503-661-9800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD15055
License Number StateOR

VIII. Authorized Official

Name: RHONDA L WALLINGFORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-661-9700