Provider Demographics
NPI:1134369978
Name:NATIONAL COLLEGE OF NATURAL MEDICINE
Entity type:Organization
Organization Name:NATIONAL COLLEGE OF NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO AND DEAN OF CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:IDA
Authorized Official - Last Name:DEHEN
Authorized Official - Suffix:
Authorized Official - Credentials:NC, LAC
Authorized Official - Phone:503-552-1551
Mailing Address - Street 1:3025 SW CORBETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4858
Mailing Address - Country:US
Mailing Address - Phone:503-552-1551
Mailing Address - Fax:
Practice Address - Street 1:3025 SW CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4858
Practice Address - Country:US
Practice Address - Phone:503-552-1551
Practice Address - Fax:503-226-8133
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATURAL COLLEGE OF NATURAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0879261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025087000OtherBLUE CROSS BLUE SHIELD
OR137646Medicaid