Provider Demographics
NPI:1457692444
Name:MEDIPRO DIRECT SLIM, LLC
Entity Type:Organization
Organization Name:MEDIPRO DIRECT SLIM, LLC
Other - Org Name:MEDIPRO HOLISTIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KYSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-828-9265
Mailing Address - Street 1:17933 NW EVERGREEN PKWY STE 285
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7513
Mailing Address - Country:US
Mailing Address - Phone:503-828-9265
Mailing Address - Fax:503-303-8997
Practice Address - Street 1:17933 NW EVERGREEN PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7659
Practice Address - Country:US
Practice Address - Phone:503-828-9265
Practice Address - Fax:503-828-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 133N00000X, 171100000X, 175F00000X, 2081P2900X, 208VP0000X, 208VP0014X, 261QM1300X, 363L00000X
OR1430175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty