Provider Demographics
NPI:1356881569
Name:NORTHWEST LICE CENTERS INC
Entity type:Organization
Organization Name:NORTHWEST LICE CENTERS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-724-4204
Mailing Address - Street 1:PO BOX 25829
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97298-0829
Mailing Address - Country:US
Mailing Address - Phone:503-404-0475
Mailing Address - Fax:
Practice Address - Street 1:5201 SW WESTGATE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2412
Practice Address - Country:US
Practice Address - Phone:503-404-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty