Provider Demographics
NPI:1689727265
Name:SCHOLLS PEDIATRIC CLINIC LLC
Entity type:Organization
Organization Name:SCHOLLS PEDIATRIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKLOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-579-3214
Mailing Address - Street 1:12442 SW SCHOLLS FERRY RD
Mailing Address - Street 2:#205
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:#205
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3396
Practice Address - Country:US
Practice Address - Phone:503-579-3214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3542358261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty