Provider Demographics
NPI:1518609973
Name:CASCADE FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:CASCADE FAMILY PRACTICE LLC
Other - Org Name:CASCADE FAMILY PRACTICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-233-5273
Mailing Address - Street 1:6542 SE LAKE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:503-233-5273
Mailing Address - Fax:855-492-8902
Practice Address - Street 1:6542 SE LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2245
Practice Address - Country:US
Practice Address - Phone:503-233-5273
Practice Address - Fax:855-492-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22663-9Medicaid