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Organization
INTERSTATE MEDICAL GROUP LLC
Active
Organization
INTERSTATE MEDICAL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL LOGIUDICE DC (OWNER)
(503) 339-7351
Entity
Organization
Contact information
Practice address
17221 SE DIVISION ST, PORTLAND, OR 97236-1240
(503) 760-0778
(503) 760-0753
Mailing address
17221 SE DIVISION ST, PORTLAND, OR 97236-1240
(503) 760-0778
(503) 760-0753
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
—
NULL
111N00000X
Chiropractor
—
—
225700000X
Massage Therapist
—
NULL
225700000X
Massage Therapist
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
NULL
261QM2500X
Medical Specialty Clinic/Center
Primary
—
NULL
Other
Enumeration date
06/14/2022
Last updated
08/24/2022
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