Provider Demographics
NPI:1639352594
Name:ROSE CITY BREAST CARE, LLC
Entity Type:Organization
Organization Name:ROSE CITY BREAST CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLINGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-661-9700
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-661-9700
Mailing Address - Fax:503-661-9800
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:SUITE 301
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-661-9700
Practice Address - Fax:503-661-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15055208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117784Medicare PIN
ORA51239Medicare UPIN