Provider Demographics
NPI:1407190952
Name:FANNO CREEK HEALING ARTS LLP
Entity Type:Organization
Organization Name:FANNO CREEK HEALING ARTS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ND, LAC
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-277-3699
Mailing Address - Street 1:4530 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0504
Mailing Address - Country:US
Mailing Address - Phone:503-277-3699
Mailing Address - Fax:
Practice Address - Street 1:4530 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0504
Practice Address - Country:US
Practice Address - Phone:503-277-3699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3156111N00000X
ORAC156029171100000X
OR1881175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty