Healthcare Provider Details

I. General information

NPI: 1083734511
Provider Name (Legal Business Name): SCHMUCKLEY ENTERPRISES INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13110 NE BEECH ST
PORTLAND OR
97230-2847
US

IV. Provider business mailing address

13110 NE BEECH ST
PORTLAND OR
97230-2847
US

V. Phone/Fax

Practice location:
  • Phone: 503-254-5669
  • Fax:
Mailing address:
  • Phone: 503-254-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number089003023RN
License Number StateOR

VIII. Authorized Official

Name: LISA MARIE SCHMUCKLEY
Title or Position: PRESIDENT
Credential: RN
Phone: 503-254-5669