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General NPI Number Information
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NPI Number | 1649838590
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Entity Type | Organization
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Legal Business Name | BOULDER CARE PROVIDER GROUP PA
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Dates
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Enumeration Date | 06/04/2019
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Last Update Date | 06/26/2024
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Provider Practice Location Address
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Address Line | 111 SW NAITO PKWY STE 200
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City | PORTLAND
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State | OR
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Zip | 97204-3512
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Country | US
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Telephone | 888-316-0451
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Fax |
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Provider Business Mailing Address
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Address Line | 111 SW NAITO PKWY STE 200
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City | PORTLAND
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State | OR
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Zip | 97204-3512
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Country | US
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Telephone | 503-208-5061
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Fax | 833-260-2594
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Authorized Official
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Title or Position | VP OPERATIONS, AUTHORIZED AGENT
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Name | MRS. PIA SHIVDASANI
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Credential |
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Telephone | 888-288-4715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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