Provider Demographics
NPI:1053777235
Name:TIM A. PEREZ, LLC
Entity type:Organization
Organization Name:TIM A. PEREZ, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:503-389-1500
Mailing Address - Street 1:7105 SW VARNS ST
Mailing Address - Street 2:#270
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7105 SW VARNS ST
Practice Address - Street 2:#270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8148
Practice Address - Country:US
Practice Address - Phone:503-389-1500
Practice Address - Fax:800-974-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950089NP261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)