Provider Demographics
NPI:1679199335
Name:ALTER IMAGE, INC.
Entity Type:Organization
Organization Name:ALTER IMAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOZLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LE, CPE
Authorized Official - Phone:503-267-3166
Mailing Address - Street 1:6340 SE CLATSOP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-0716
Mailing Address - Country:US
Mailing Address - Phone:503-267-3166
Mailing Address - Fax:
Practice Address - Street 1:2340 SE GLADSTONE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2962
Practice Address - Country:US
Practice Address - Phone:503-267-3166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty