Healthcare Provider Details

I. General information

NPI: 1467428730
Provider Name (Legal Business Name): KELLY M LASCHKEWITSCH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 NW 22ND AVE SUITE 520
PORTLAND OR
97210-3057
US

IV. Provider business mailing address

6605 N CONCORD AVE
PORTLAND OR
97217-4803
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-8135
  • Fax:
Mailing address:
  • Phone: 503-413-8135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: