Healthcare Provider Details

I. General information

NPI: 1386787885
Provider Name (Legal Business Name): ALISA M TORTORICH RD, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD UHS-18
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

9517 N WOOLSEY AVE
PORTLAND OR
97203
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-5257
  • Fax: 503-494-3769
Mailing address:
  • Phone: 503-830-8948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number568
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: