Provider Demographics
NPI:1801226527
Name:EDWARD ILDOE BAE
Entity Type:Organization
Organization Name:EDWARD ILDOE BAE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ILDOE
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-646-3743
Mailing Address - Street 1:13755 SW FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2603
Mailing Address - Country:US
Mailing Address - Phone:503-646-3743
Mailing Address - Fax:503-646-5200
Practice Address - Street 1:13755 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2603
Practice Address - Country:US
Practice Address - Phone:503-646-3743
Practice Address - Fax:503-646-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00115171100000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty