Provider Demographics
NPI:1356905855
Name:ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC
Entity type:Organization
Organization Name:ILLUMINATION ROCK INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:ISAKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:971-229-2140
Mailing Address - Street 1:4035 SE 52ND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3913
Mailing Address - Country:US
Mailing Address - Phone:971-229-2140
Mailing Address - Fax:971-244-9171
Practice Address - Street 1:4035 SE 52ND AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3913
Practice Address - Country:US
Practice Address - Phone:503-482-7556
Practice Address - Fax:971-244-9171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932568458OtherNPI TYPE 1
OR500703138Medicaid