Basic Information
Provider Information | |||||||||
NPI: | 1023065307 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COL NORTHWEST LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLEARVIEW MRI MT SCOTT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9200 SE 91ST AVE | ||||||||
Address2: | SUITE 330 | ||||||||
City: | HAPPY VALLEY | ||||||||
State: | OR | ||||||||
PostalCode: | 970863756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037747700 | ||||||||
FaxNumber: | 5037747701 | ||||||||
Practice Location | |||||||||
Address1: | 9200 SE 91ST AVE | ||||||||
Address2: | SUITE 330 | ||||||||
City: | HAPPY VALLEY | ||||||||
State: | OR | ||||||||
PostalCode: | 970863756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037747700 | ||||||||
FaxNumber: | 5037747701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 03/25/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ORIN | ||||||||
AuthorizedOfficialFirstName: | DARCY | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5037747700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X |   |   | Y |   | Laboratories | Physiological Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 276104 | 05 | OR |   | MEDICAID |