MEDICARE: AT HOME PRIMARY CARE 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
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1427447143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AT HOME PRIMARY CARE LLC.

Provider Business Mailing Address
First Line	:	6400 SE LAKE RD # 420
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97222-2129
Country	:	US
Telephone Number	:	503-344-6717
Fax Number	:

Provider Business Practice Location Address
First Line	:	6400 SE LAKE RD # 420
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97222-2129
Country	:	US
Telephone Number	:	503-344-6717
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SUZIE ANNETTE DAVIS
Credential	:
Telephone Number	:	503-344-6717

Provider Enumeration Date	:	01/19/2015
Last Update Date	:	02/12/2015

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