Healthcare Provider Details

I. General information

NPI: 1154985752
Provider Name (Legal Business Name): DDCHEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 10/12/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 NW QUIMBY ST APT 515
PORTLAND OR
97209
US

IV. Provider business mailing address

3055 NW YEON AVE # 595
PORTLAND OR
97210-1519
US

V. Phone/Fax

Practice location:
  • Phone: 503-496-7704
  • Fax: 971-375-4420
Mailing address:
  • Phone: 503-496-7704
  • Fax: 971-375-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DUSTIN CARLSON
Title or Position: PROVIDER GENERAL MANAGER
Credential: FNP-BC
Phone: 503-944-9727