Healthcare Provider Details

I. General information

NPI: 1952087678
Provider Name (Legal Business Name): NORTHWEST EXTREMITY SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
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

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

V. Phone/Fax

Practice location:
  • Phone: 503-352-1313
  • Fax: 503-352-1314
Mailing address:
  • Phone:
  • 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: MERIDIAN PARK
Title or Position: AREA OPERATIONS DIRECTOR
Credential:
Phone: 503-577-2964