Provider Demographics
NPI:1073023941
Name:SACRED VESSEL NATURAL MEDICINE
Entity type:Organization
Organization Name:SACRED VESSEL NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-459-2584
Mailing Address - Street 1:4115 N MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3130
Mailing Address - Country:US
Mailing Address - Phone:503-459-2584
Mailing Address - Fax:503-893-3087
Practice Address - Street 1:4115 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3130
Practice Address - Country:US
Practice Address - Phone:503-459-2584
Practice Address - Fax:503-893-3087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1875175F00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667244Medicaid