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NPI Code Detail

MEDICARE: ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC

MEDICARE: ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC
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
12081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician
2171100000XAcupuncturist
3175F00000XNaturopath
42081N0008XNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
5225700000XMassage Therapist
6261Q00000XClinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11932568458OTHERNPI TYPE 1
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1356905855
Entity Type Code : Organization
Provider Name (Legal Business Name) : ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC
Provider Business Mailing Address
First Line : 4035 SE 52ND AVE STE B
Second Line :
City : PORTLAND
State : OR
Zip : 97206-3913
Country : US
Telephone Number : 971-229-2140
Fax Number : 971-244-9171
Provider Business Practice Location Address
First Line : 4035 SE 52ND AVE STE B
Second Line :
City : PORTLAND
State : OR
Zip : 97206-3913
Country : US
Telephone Number : 503-482-7556
Fax Number : 971-244-9171
Authorized Official
Title or Position : MANAGING MEMBER
Name : KIRSTEN KAREN ISAKSON
Credential : LAC
Telephone Number : 971-229-2140
Provider Enumeration Date : 04/30/2019
Last Update Date : 03/30/2022

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Directions to “ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC ” Practice Location

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