Healthcare Provider Details

I. General information

NPI: 1124890066
Provider Name (Legal Business Name): MIRIAM ESCOBAR MANRIQUEZ THW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 503-418-5700
  • Fax: 503-418-5704
Mailing address:
  • Phone: 503-418-5700
  • Fax: 503-418-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number109835
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: