Provider Demographics
NPI:1316656994
Name:MOUNTAIN WEST DERM-BLACKHART, PLLC
Entity type:Organization
Organization Name:MOUNTAIN WEST DERM-BLACKHART, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHACKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-283-4086
Mailing Address - Street 1:10215 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8809
Mailing Address - Country:US
Mailing Address - Phone:503-245-2415
Mailing Address - Fax:503-244-5963
Practice Address - Street 1:10215 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8809
Practice Address - Country:US
Practice Address - Phone:503-245-2415
Practice Address - Fax:503-244-5963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN WEST DERM-BLACKHART, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty