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General NPI Number Information
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NPI Number | 1205172913
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Entity Type | Organization
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Legal Business Name | THE GOLDEN ROOM LLC
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Dates
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Enumeration Date | 12/27/2012
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Last Update Date | 12/27/2012
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Provider Practice Location Address
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Address Line | 636 SE 49TH AVE
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City | PORTLAND
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State | OR
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Zip | 97215-1728
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Country | US
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Telephone | 971-506-4560
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Fax |
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Provider Business Mailing Address
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Address Line | 4360 NE SIMPSON ST
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City | PORTLAND
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State | OR
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Zip | 97218-1444
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Country | US
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Telephone | 971-506-4560
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Fax |
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Authorized Official
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Title or Position | OWNER/LMT
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Name | MAURI MCKITRICK
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Credential |
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Telephone | 971-506-4560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 8161
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License Number State | OR
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