Basic Information
| Provider Information | |||||||||
| NPI: | 1649555145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRIDA CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 SW CANYON CT | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972211459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034779616 | ||||||||
| FaxNumber: | 5034779808 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 SW CANYON CT | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972211461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034779616 | ||||||||
| FaxNumber: | 5034779808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2011 | ||||||||
| LastUpdateDate: | 10/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | LIPTAN | ||||||||
| AuthorizedOfficialFirstName: | GINEVRA | ||||||||
| AuthorizedOfficialMiddleName: | LOIS | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5034779616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 28421 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.