Healthcare Provider Details

I. General information

NPI: 1710271861
Provider Name (Legal Business Name): LUKEDORF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SW 6TH ST
GRESHAM OR
97080-9475
US

IV. Provider business mailing address

10313 69TH AVE
TIGARD OR
97223
US

V. Phone/Fax

Practice location:
  • Phone: 503-726-3806
  • Fax:
Mailing address:
  • Phone: 503-726-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. MEGAN WIEGEL
Title or Position: HR
Credential:
Phone: 503-726-3698