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General NPI Number Information
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NPI Number | 1407128309
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Entity Type | Organization
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Legal Business Name | GIFT OF LIFE CLINIC
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Dates
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Enumeration Date | 02/08/2012
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Last Update Date | 02/08/2012
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Provider Practice Location Address
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Address Line | 4259 NE BROADWAY ST
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City | PORTLAND
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State | OR
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Zip | 97213-1421
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Country | US
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Telephone | 503-235-2259
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Fax |
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Provider Business Mailing Address
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Address Line | 4259 NE BROADWAY ST
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City | PORTLAND
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State | OR
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Zip | 97213-1421
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Country | US
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Telephone | 503-235-2259
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Fax |
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Authorized Official
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Title or Position | CO-OWNER, NATUROPATHIC DOCTOR
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Name | DR. MIA CRUPPER
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Credential | N.D., L.M.T
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Telephone | 503-235-2259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 176B00000X
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Taxonomy Name | Midwife
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License Number | 84-OB
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 7621
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 175F00000X
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Taxonomy Name | Naturopath
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License Number | 1481 & 1618
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License Number State | OR
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