Healthcare Provider Details

I. General information

NPI: 1477162360
Provider Name (Legal Business Name): MK ORTHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6485 SW BORLAND RD STE A
TUALATIN OR
97062-9762
US

IV. Provider business mailing address

2351 NW WESTOVER RD UNIT 706
PORTLAND OR
97210-3783
US

V. Phone/Fax

Practice location:
  • Phone: 503-692-5483
  • Fax:
Mailing address:
  • Phone: 817-966-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MELISSA KOUNINE
Title or Position: OWNER
Credential: DO
Phone: 817-966-4689