Provider Demographics
NPI:1578031746
Name:PEACH SKIN NORTH PORTLAND HEALTHCARE LLC
Entity Type:Organization
Organization Name:PEACH SKIN NORTH PORTLAND HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:JAQUELINE
Authorized Official - Middle Name:LOPES
Authorized Official - Last Name:BROCKERT
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:971-413-3207
Mailing Address - Street 1:3537 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1437
Mailing Address - Country:US
Mailing Address - Phone:971-413-3207
Mailing Address - Fax:503-477-8107
Practice Address - Street 1:3537 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1437
Practice Address - Country:US
Practice Address - Phone:971-413-3207
Practice Address - Fax:503-477-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty