Provider Demographics
NPI:1245946854
Name:IBOLIT MANUAL MEDICINE PC.
Entity type:Organization
Organization Name:IBOLIT MANUAL MEDICINE PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPE
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:971-419-2066
Mailing Address - Street 1:18633 SE STARK STREET. BLDG A, SUITE 314
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:98233
Mailing Address - Country:US
Mailing Address - Phone:971-419-2066
Mailing Address - Fax:
Practice Address - Street 1:18633 SE STARK ST STE 205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5468
Practice Address - Country:US
Practice Address - Phone:503-676-3131
Practice Address - Fax:503-676-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty