Provider Demographics
NPI:1508055781
Name:CREEKSIDE FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:CREEKSIDE FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CRONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-239-7030
Mailing Address - Street 1:9200 SE 91ST AVE
Mailing Address - Street 2:SUITE #220
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3756
Mailing Address - Country:US
Mailing Address - Phone:503-239-7030
Mailing Address - Fax:503-239-7220
Practice Address - Street 1:9200 SE 91ST AVE
Practice Address - Street 2:SUITE #220
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3756
Practice Address - Country:US
Practice Address - Phone:503-239-7030
Practice Address - Fax:503-239-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty