Provider Demographics
NPI:1154791275
Name:FOREST MEDICINE LLC
Entity type:Organization
Organization Name:FOREST MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:OLIVIA
Authorized Official - Last Name:KLOOS
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-250-0440
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:CORBETT
Mailing Address - State:OR
Mailing Address - Zip Code:97019-0116
Mailing Address - Country:US
Mailing Address - Phone:503-250-0440
Mailing Address - Fax:
Practice Address - Street 1:22400 SE STARK ST STE 105
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2656
Practice Address - Country:US
Practice Address - Phone:503-250-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:94985497
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1798175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty