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General NPI Number Information
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NPI Number | 1346492964
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Entity Type | Organization
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Legal Business Name | PROACTIVE HEALTH RESOURCES, LLC
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Dates
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Enumeration Date | 10/14/2008
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Last Update Date | 10/14/2008
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Provider Practice Location Address
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Address Line | 4077 JEFFERSON PKWY
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-1478
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Country | US
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Telephone | 503-342-6202
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Fax |
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Provider Business Mailing Address
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Address Line | 4077 JEFFERSON PKWY
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-1478
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Country | US
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Telephone | 503-342-6202
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MS. PHYLLIS VANDERVEER
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Credential | RN
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Telephone | 503-342-6202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 9142
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License Number State | OR
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