Provider Demographics
NPI:1558607812
Name:FERTILE GROUND FAMILY CENTER, LLC
Entity Type:Organization
Organization Name:FERTILE GROUND FAMILY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PHD, MPH, LDM
Authorized Official - Phone:503-284-6195
Mailing Address - Street 1:3575 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1820
Mailing Address - Country:US
Mailing Address - Phone:503-284-6195
Mailing Address - Fax:
Practice Address - Street 1:3575 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1820
Practice Address - Country:US
Practice Address - Phone:503-284-6195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10144749261QB0400X
OR2921261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing