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General NPI Number Information
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NPI Number | 1215471909
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Entity Type | Organization
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Legal Business Name | NORTHWEST MOTHERS MILK BANK
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Dates
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Enumeration Date | 12/14/2016
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Last Update Date | 04/22/2020
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Provider Practice Location Address
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Address Line | 15875 SW 74TH AVE STE 100
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City | TIGARD
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State | OR
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Zip | 97224-7934
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Country | US
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Telephone | 503-469-9555
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Fax | 503-469-0962
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Provider Business Mailing Address
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Address Line | 15875 SW 74TH AVE STE 100
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City | TIGARD
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State | OR
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Zip | 97224-7934
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Country | US
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Telephone | 503-469-9555
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Fax | 503-469-0962
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LESLEY L MONDEAUX
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Credential | RNC,IBCLC
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Telephone | 503-332-0436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number | 542742-96
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number | 542742-96
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License Number State | OR
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