Provider Demographics
NPI:1174388250
Name:ALTA ULRICH, LMT LLC
Entity type:Organization
Organization Name:ALTA ULRICH, LMT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-501-6312
Mailing Address - Street 1:PO BOX 3633
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0398
Mailing Address - Country:US
Mailing Address - Phone:503-907-0890
Mailing Address - Fax:833-638-0790
Practice Address - Street 1:21707 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2029
Practice Address - Country:US
Practice Address - Phone:503-907-0890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:884423374
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty