1730486267 NPI number — KATRINA FAIRCHILD FRAIJO

Table of content: KATRINA FAIRCHILD FRAIJO (NPI 1730486267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730486267 NPI number — KATRINA FAIRCHILD FRAIJO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRAIJO
Provider First Name:
KATRINA
Provider Middle Name:
FAIRCHILD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1730486267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1206 SW CARSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97219-4331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-235-9420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10180 SE SUNNYSIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-8970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-645-3772
Provider Business Practice Location Address Fax Number:
503-571-2206
Provider Enumeration Date:
02/18/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: L5149 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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