Provider Demographics
NPI:1407177934
Name:OREGON COSMETIC AND RECONSTRUCTIVE CLINIC, PC
Entity Type:Organization
Organization Name:OREGON COSMETIC AND RECONSTRUCTIVE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-400-6622
Mailing Address - Street 1:PO BOX 66500
Mailing Address - Street 2:PO
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6500
Mailing Address - Country:US
Mailing Address - Phone:503-657-8663
Mailing Address - Fax:503-723-3180
Practice Address - Street 1:10202 SE 32ND AVE
Practice Address - Street 2:SUITE 702
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-3610
Practice Address - Country:US
Practice Address - Phone:503-400-6622
Practice Address - Fax:503-400-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty