MEDICARE: EARTH SOURCE MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center		OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164952495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EARTH SOURCE MEDICINE

Provider Business Mailing Address
First Line	:	757 W MARINE DR STE 103
Second Line	:
City	:	ASTORIA
State	:	OR
Zip	:	97103-5848
Country	:	US
Telephone Number	:	207-209-4858
Fax Number	:	207-405-2199

Provider Business Practice Location Address
First Line	:	757 W MARINE DR STE 103
Second Line	:
City	:	ASTORIA
State	:	OR
Zip	:	97103-5848
Country	:	US
Telephone Number	:	207-209-4858
Fax Number	:	207-405-2199

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CAROLYN IACULLO NYGAARD
Credential	:
Telephone Number	:	207-209-4858

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	04/21/2026

Similar Medicare Providers

1649500646 — DR. CAROLYN IACULLO NYGAARD N.D
Practice Location Address:

757 W MARINE DR STE 103
ASTORIA, OR
97103-5848

Practice Phone: 207-209-4858
Practice Fax: 207-405-2199

1770366502 — KELLY SAWYER PMHNP
Practice Location Address:

757 W MARINE DR STE 104
ASTORIA, OR
97103-5848

Practice Phone: 503-366-4850
Practice Fax: 888-971-4017

1275347155 — ZACHARY ALLEN HALE LCSW
Practice Location Address:

2275 COMMERCIAL ST
ASTORIA, OR
97103-3327

Practice Phone: 503-325-8315
Practice Fax:

1811887573 — LISA ANN JIMENEZ PMHNP
Practice Location Address:

2275 COMMERCIAL ST
ASTORIA, OR
97103-3327

Practice Phone: 503-325-8315
Practice Fax:

1093238636 — ASHLYN SWERDLOFF DO
Practice Location Address:

2158 EXCHANGE ST STE 206
ASTORIA, OR
97103-3307

Practice Phone: 503-325-7337
Practice Fax: 503-325-3706

1508790098 — KIRSTEN RITCHIE
Practice Location Address:

2275 COMMERCIAL ST
ASTORIA, OR
97103-3327

Practice Phone: 503-325-8315
Practice Fax:

Directions to “EARTH SOURCE MEDICINE ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.