Healthcare Provider Details

I. General information

NPI: 1356905855
Provider Name (Legal Business Name): ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 SE 52ND AVE STE B
PORTLAND OR
97206-3913
US

IV. Provider business mailing address

4035 SE 52ND AVE STE B
PORTLAND OR
97206-3913
US

V. Phone/Fax

Practice location:
  • Phone: 503-482-7556
  • Fax: 971-244-9171
Mailing address:
  • Phone: 971-229-2140
  • Fax: 971-244-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN KAREN ISAKSON
Title or Position: MANAGING MEMBER
Credential: LAC
Phone: 971-229-2140