Provider Demographics
NPI:1790179323
Name:ELYSIUM HEALTH COOPERATIVE
Entity Type:Organization
Organization Name:ELYSIUM HEALTH COOPERATIVE
Other - Org Name:EHCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-765-6020
Mailing Address - Street 1:20625 SW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6323
Mailing Address - Country:US
Mailing Address - Phone:503-765-6020
Mailing Address - Fax:503-741-2184
Practice Address - Street 1:25195 SW PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9651
Practice Address - Country:US
Practice Address - Phone:503-765-6020
Practice Address - Fax:503-741-2184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2042261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care