Healthcare Provider Details

I. General information

NPI: 1922759174
Provider Name (Legal Business Name): MOUNTAIN LIFE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67195 E HIGHWAY 26
WELCHES OR
97067-9610
US

IV. Provider business mailing address

118 N KILLINGSWORTH ST
PORTLAND OR
97217-2435
US

V. Phone/Fax

Practice location:
  • Phone: 503-288-4454
  • Fax: 503-288-1783
Mailing address:
  • Phone: 503-288-4454
  • Fax: 503-288-1783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: AMBER POTTER
Title or Position: BILLING SPECIALIST
Credential:
Phone: 503-288-4454