Healthcare Provider Details

I. General information

NPI: 1962799833
Provider Name (Legal Business Name): TRINITY SHERADEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MONEDA AVE N
KEIZER OR
97303-6256
US

IV. Provider business mailing address

2263 NE CORNELL RD
HILLSBORO OR
97124-5947
US

V. Phone/Fax

Practice location:
  • Phone: 503-869-7380
  • Fax: 866-548-6743
Mailing address:
  • Phone: 503-869-7380
  • Fax: 866-548-6743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7300
License Number StateOR

VIII. Authorized Official

Name: TRINITY SHERADEN
Title or Position: OWNER
Credential: LMT
Phone: 503-869-7380