=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083300628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OREGON TRAIL INTEGRATIVE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2023
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17500 STRAUSS AVE
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97055-8060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-668-5822
-----------------------------------------------------
Fax | 503-668-3662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 909
-----------------------------------------------------
City | BORING
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97009-0909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-668-5822
-----------------------------------------------------
Fax | 503-668-3662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN CLIFTON RHUE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 503-201-7532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------