Healthcare Provider Details

I. General information

NPI: 1669095287
Provider Name (Legal Business Name): COYOTE RESOLVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12923 NW CORNELL RD STE 201
PORTLAND OR
97229-5834
US

IV. Provider business mailing address

14355 SW ROCHESTER DR
BEAVERTON OR
97008-4931
US

V. Phone/Fax

Practice location:
  • Phone: 503-646-3393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: STEVE HANSON
Title or Position: MANAGER
Credential: DC
Phone: 503-956-9065