MEDICARE: NORTHWEST IV, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	363LA2100X	Acute Care Nurse Practitioner
3	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1225619703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST IV, LLC

Provider Business Mailing Address
First Line	:	6400 SE LAKE RD STE 155
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97222-2137
Country	:	US
Telephone Number	:	503-447-3285
Fax Number	:	503-917-4971

Provider Business Practice Location Address
First Line	:	2255 NW SHEVLIN PARK RD STE 110
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7134
Country	:	US
Telephone Number	:	541-728-2525
Fax Number	:	971-223-0919

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	JOHN PERRY
Credential	:
Telephone Number	:	971-358-9292

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	02/05/2026

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