1548632532 NPI number — NORTHWEST INTEGRATIVE MEDICINE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548632532 NPI number — NORTHWEST INTEGRATIVE MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST INTEGRATIVE MEDICINE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548632532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15875 SW 72ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-252-8459
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19365 SW 65TH AVE
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-9196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-765-6020
Provider Business Practice Location Address Fax Number:
504-741-2184
Provider Enumeration Date:
10/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
MAEGHAN
Authorized Official Middle Name:
CULVER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-855-4341

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X , with the licence number:  3005 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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