Basic Information
| Provider Information | |||||||||
| NPI: | 1144250168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROJECT QUEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032385203 | ||||||||
| FaxNumber: | 5032385202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032385203 | ||||||||
| FaxNumber: | 5032385202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EISEN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5032385203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | LAC, DOM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | DO19964 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 103TC1900X | 1690 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 363LP0808X | 087006211N6 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 103TC1900X | 964 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 175F00000X | 0896 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Naturopath | 171100000X | AC00106 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 101YA0400X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TA0400X | 964 | OR | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 150591 | 05 | OR | MEDICAID | 223347 | 05 | OR | MEDICAID | 083373 | 05 | OR | MEDICAID | 298940 | 05 | OR | MEDICAID | 028298 | 05 | OR | MEDICAID | 240090 | 05 | OR | MEDICAID |