Healthcare Provider Details

I. General information

NPI: 1033647201
Provider Name (Legal Business Name): CHITARI FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16144 SE HAPPY VALLEY TOWN CENTER DR STE 214
HAPPY VALLEY OR
97086-4257
US

IV. Provider business mailing address

16144 SE HAPPY VALLEY TOWN CENTER DR STE 214
HAPPY VALLEY OR
97086-4257
US

V. Phone/Fax

Practice location:
  • Phone: 503-400-9397
  • Fax:
Mailing address:
  • Phone: 503-400-9397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number00217
License Number StateOR

VIII. Authorized Official

Name: DR. CHANTELLE BALDWIN
Title or Position: BOARD MEMBER
Credential: DO ND
Phone: 503-400-9397