Provider Demographics
NPI:1164952495
Name:EARTH SOURCE MEDICINE
Entity Type:Organization
Organization Name:EARTH SOURCE MEDICINE
Other - Org Name:ASTORIA INTEGRATIVE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:IACULLO
Authorized Official - Last Name:NYGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-741-3636
Mailing Address - Street 1:1490 COMMERCIAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3800
Mailing Address - Country:US
Mailing Address - Phone:503-741-3636
Mailing Address - Fax:
Practice Address - Street 1:1490 COMMERCIAL ST STE 200
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3800
Practice Address - Country:US
Practice Address - Phone:503-741-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500642404Medicaid