=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750653648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST NATUROPATHIC CLINC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1540 SE CLINTON ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-8083
-----------------------------------------------------
Fax | 503-224-5883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1540 SE CLINTON ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-8083
-----------------------------------------------------
Fax | 503-224-5883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. SUSAN RAE LEMASTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-224-8083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 59-540
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------