Provider Demographics
NPI:1033674841
Name:JEREMY MIKOLAI ND INC
Entity Type:Organization
Organization Name:JEREMY MIKOLAI ND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MIKOLAI
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:507-327-4451
Mailing Address - Street 1:4110 SE HAWTHORNE BLVD # 132
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5246
Mailing Address - Country:US
Mailing Address - Phone:507-800-0056
Mailing Address - Fax:844-965-9136
Practice Address - Street 1:2540 NE M L KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3732
Practice Address - Country:US
Practice Address - Phone:507-800-0056
Practice Address - Fax:844-965-9136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care