Healthcare Provider Details

I. General information

NPI: 1376472910
Provider Name (Legal Business Name): LOCKLAB PROVIDER GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 COMMERCIAL ST SE STE 100
SALEM OR
97301-3465
US

IV. Provider business mailing address

10260 SW GREENBURG RD STE 400
PORTLAND OR
97223-5514
US

V. Phone/Fax

Practice location:
  • Phone: 305-425-9125
  • Fax:
Mailing address:
  • Phone: 305-425-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BOBBY DESAI
Title or Position: PRESIDENT
Credential: MD
Phone: 305-425-9125