Provider Demographics
NPI:1902013725
Name:BEAVERTON WEIGHT LOSS & FAMILY PRACTICE
Entity Type:Organization
Organization Name:BEAVERTON WEIGHT LOSS & FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KNAUS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:503-330-7025
Mailing Address - Street 1:13292 SW 161ST PL
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2677
Mailing Address - Country:US
Mailing Address - Phone:503-330-7025
Mailing Address - Fax:
Practice Address - Street 1:13292 SW 161ST PL
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2677
Practice Address - Country:US
Practice Address - Phone:503-330-7025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR99007644261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130247Medicare ID - Type UnspecifiedPAIN MGMT CONSULTANTS
ORP28798Medicare UPIN
OR110388Medicare ID - Type UnspecifiedBVTN WT LOSS & FAM PRACT