1407177934 NPI number — OREGON COSMETIC AND RECONSTRUCTIVE CLINIC, PC

Table of content: (NPI 1407177934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407177934 NPI number — OREGON COSMETIC AND RECONSTRUCTIVE CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREGON COSMETIC AND RECONSTRUCTIVE CLINIC, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407177934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66500
Provider Second Line Business Mailing Address:
PO
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97290-6500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-8663
Provider Business Mailing Address Fax Number:
503-723-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10202 SE 32ND AVE
Provider Second Line Business Practice Location Address:
SUITE 702
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-3610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-400-6622
Provider Business Practice Location Address Fax Number:
503-400-6622
Provider Enumeration Date:
06/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JENQ
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-400-6622

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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