Healthcare Provider Details

I. General information

NPI: 1356881569
Provider Name (Legal Business Name): NORTHWEST LICE CENTERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 SW WESTGATE DR SUITE 106
PORTLAND OR
97221-2412
US

IV. Provider business mailing address

PO BOX 25829
PORTLAND OR
97298-0829
US

V. Phone/Fax

Practice location:
  • Phone: 503-404-0475
  • Fax:
Mailing address:
  • Phone: 503-404-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARK S MEYER
Title or Position: PRESIDENT
Credential:
Phone: 503-724-4204