Provider Demographics
NPI:1821730417
Name:POWERED BY SELF LOVE OREGON LLC
Entity Type:Organization
Organization Name:POWERED BY SELF LOVE OREGON LLC
Other - Org Name:POWERED BY SELF LOVE OREGON LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF NURSE PRAC
Authorized Official - Phone:714-880-5065
Mailing Address - Street 1:16027 BROOKHURST ST STE I-732
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1551
Mailing Address - Country:US
Mailing Address - Phone:657-321-9765
Mailing Address - Fax:229-218-2667
Practice Address - Street 1:5305 RIVER RD N STE B1
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5324
Practice Address - Country:US
Practice Address - Phone:657-321-9765
Practice Address - Fax:229-218-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-13
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty