Healthcare Provider Details

I. General information

NPI: 1023596541
Provider Name (Legal Business Name): NORTHWEST IV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 SE LAKE RD STE 155
PORTLAND OR
97222-2137
US

IV. Provider business mailing address

6400 SE LAKE RD STE 430
PORTLAND OR
97222-2129
US

V. Phone/Fax

Practice location:
  • Phone: 503-447-3285
  • Fax: 503-917-4971
Mailing address:
  • Phone: 503-447-3285
  • Fax: 503-917-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201392160NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD22534
License Number StateOR

VIII. Authorized Official

Name: JOHN PERRY
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 503-447-3285