Provider Demographics
NPI:1215471909
Name:NORTHWEST MOTHERS MILK BANK
Entity type:Organization
Organization Name:NORTHWEST MOTHERS MILK BANK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:RNC,IBCLC
Authorized Official - Phone:503-332-0436
Mailing Address - Street 1:15875 SW 74TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7934
Mailing Address - Country:US
Mailing Address - Phone:503-469-9555
Mailing Address - Fax:503-469-0962
Practice Address - Street 1:15875 SW 74TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7934
Practice Address - Country:US
Practice Address - Phone:503-469-9555
Practice Address - Fax:503-469-0962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR542742-96251V00000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No251V00000XAgenciesVoluntary or Charitable