Provider Demographics
NPI:1093594392
Name:LIBERTY BLANK, N.D., LLC
Entity Type:Organization
Organization Name:LIBERTY BLANK, N.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-944-1138
Mailing Address - Street 1:164 NW MACLEAY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12755 SW 69TH AVENUE
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-944-1138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY BLANK, N.D., LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty