Provider Demographics
NPI:1316425010
Name:PORTLAND AUDIOLOGY CLINIC, LLC
Entity type:Organization
Organization Name:PORTLAND AUDIOLOGY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARALYN
Authorized Official - Middle Name:DENNISE
Authorized Official - Last Name:MARTINDALE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:503-227-3668
Mailing Address - Street 1:9735 SW SHADY LN STE 302
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5481
Mailing Address - Country:US
Mailing Address - Phone:503-227-3668
Mailing Address - Fax:503-227-2234
Practice Address - Street 1:9735 SW SHADY LN STE 302
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5481
Practice Address - Country:US
Practice Address - Phone:503-227-3668
Practice Address - Fax:503-227-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR30820231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14284488OtherCAQH