Provider Demographics
NPI:1659792620
Name:HEALTHSOURCE OF SE PORTLAND
Entity Type:Organization
Organization Name:HEALTHSOURCE OF SE PORTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-641-4244
Mailing Address - Street 1:5424 SE 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4811
Mailing Address - Country:US
Mailing Address - Phone:503-774-1252
Mailing Address - Fax:503-774-1271
Practice Address - Street 1:5424 SE 82ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4811
Practice Address - Country:US
Practice Address - Phone:503-774-1252
Practice Address - Fax:503-774-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty