Healthcare Provider Details

I. General information

NPI: 1124783345
Provider Name (Legal Business Name): OREGON INSTITUTE OF FOOT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 03/24/2022
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S STATE ST STE 3220
LAKE OSWEGO OR
97034-3975
US

IV. Provider business mailing address

55 S STATE ST STE 3220
LAKE OSWEGO OR
97034-3975
US

V. Phone/Fax

Practice location:
  • Phone: 503-635-7742
  • Fax:
Mailing address:
  • Phone: 503-635-7742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. TYLER MANSON
Title or Position: PODIATRIC PHYSICIAN
Credential: DPM
Phone: 503-635-7742