Provider Demographics
NPI:1659821023
Name:PRECIOUS MEMORY FAMILY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PRECIOUS MEMORY FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MORRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:503-384-2392
Mailing Address - Street 1:7620 NE KILLINGSWORTH SUIT 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218
Mailing Address - Country:US
Mailing Address - Phone:503-384-2392
Mailing Address - Fax:
Practice Address - Street 1:7620 NE KILLINGSWORTH ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-3763
Practice Address - Country:US
Practice Address - Phone:503-858-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250053NP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care