Provider Demographics
NPI:1407128309
Name:GIFT OF LIFE CLINIC
Entity Type:Organization
Organization Name:GIFT OF LIFE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, NATUROPATHIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUPPER
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LMT
Authorized Official - Phone:503-235-2259
Mailing Address - Street 1:4259 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1421
Mailing Address - Country:US
Mailing Address - Phone:503-235-2259
Mailing Address - Fax:
Practice Address - Street 1:4259 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1421
Practice Address - Country:US
Practice Address - Phone:503-235-2259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7621174400000X
OR1481 & 1618175F00000X
OR84-OB176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty