Healthcare Provider Details

I. General information

NPI: 1457568958
Provider Name (Legal Business Name): ATHENA PARADISE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 E BURNSIDE ST
PORTLAND OR
97214-1531
US

IV. Provider business mailing address

1715 E BURNSIDE ST
PORTLAND OR
97214-1531
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-4622
  • Fax: 503-788-6399
Mailing address:
  • Phone: 503-234-4622
  • Fax: 503-788-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number272272
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number272272
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number272272
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: