Healthcare Provider Details

I. General information

NPI: 1669876173
Provider Name (Legal Business Name): MEDSTAR NW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14523 WESTLAKE DR
LAKE OSWEGO OR
97035-7700
US

IV. Provider business mailing address

14523 WESTLAKE DR
LAKE OSWEGO OR
97035-7700
US

V. Phone/Fax

Practice location:
  • Phone: 503-616-8427
  • Fax:
Mailing address:
  • Phone: 503-616-8427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM THOMAS BOOTH
Title or Position: MANAGING PARTNER
Credential:
Phone: 503-616-8427