Provider Demographics
NPI:1881625820
Name:MOUNTAIN PARK HEALTH CLINIC
Entity type:Organization
Organization Name:MOUNTAIN PARK HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:RIFKIN
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-892-8788
Mailing Address - Street 1:11030 SW CAPITOL HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8653
Mailing Address - Country:US
Mailing Address - Phone:503-892-9177
Mailing Address - Fax:503-892-9177
Practice Address - Street 1:11030 SW CAPITOL HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-8653
Practice Address - Country:US
Practice Address - Phone:503-892-9177
Practice Address - Fax:503-892-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00034171100000X
OR0423175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Not Answered175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherTAX I.D.