Healthcare Provider Details

I. General information

NPI: 1679790604
Provider Name (Legal Business Name): ALLERGY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVE SUITE 1301
PORTLAND OR
97205-2732
US

IV. Provider business mailing address

511 SW 10TH AVE SUITE 1301
PORTLAND OR
97205-2732
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-0155
  • Fax: 503-226-8342
Mailing address:
  • Phone: 503-228-0155
  • Fax: 503-226-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number13450
License Number StateOR

VIII. Authorized Official

Name: DR. MARK THOMAS O'HOLLAREN
Title or Position: OWNER
Credential: M.D.
Phone: 503-228-0155