MEDICARE: ELEMENTAL 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	261QM1300X	Multi-Specialty Clinic/Center	AC153123	OR
2	261QM1300X	Multi-Specialty Clinic/Center	8058	OR
3	261QM1300X	Multi-Specialty Clinic/Center	3917	OR

General Provider Information

NPI Number	:	1316241078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEMENTAL MEDICINE

Provider Business Mailing Address
First Line	:	2915 SE BELMONT ST
Second Line	:	SUITE 1
City	:	PORTLAND
State	:	OR
Zip	:	97214
Country	:	US
Telephone Number	:	503-505-9677
Fax Number	:

Provider Business Practice Location Address
First Line	:	2915 SE BELMONT ST
Second Line	:	SUITE 1
City	:	PORTLAND
State	:	OR
Zip	:	97214
Country	:	US
Telephone Number	:	503-505-9677
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. CARRIE N EBLING
Credential	:	DC
Telephone Number	:	503-505-9677

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	01/10/2011

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Directions to “ELEMENTAL MEDICINE ” Practice Location

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