Provider Demographics
NPI:1386012029
Name:NW HEADACHE CENTER, LLC
Entity Type:Organization
Organization Name:NW HEADACHE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDONT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-665-1115
Mailing Address - Street 1:1042 NW NORMAN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5554
Mailing Address - Country:US
Mailing Address - Phone:503-665-1115
Mailing Address - Fax:
Practice Address - Street 1:1042 NW NORMAN AVE STE 210
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5554
Practice Address - Country:US
Practice Address - Phone:503-665-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9440261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental