1053895615 NPI number — DR. EMMA MICHELLE NEIWORTH PETSHOW ND

Table of content: LUIGI GRECO O.D. (NPI 1295101889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053895615 NPI number — DR. EMMA MICHELLE NEIWORTH PETSHOW ND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEIWORTH PETSHOW
Provider First Name:
EMMA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ND
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:
1053895615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13203 SE 172ND AVE STE 166
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAPPY VALLEY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97086-8738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-664-1011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13414 NE 23RD AVE
Provider Second Line Business Practice Location Address:
UNIT 427
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-664-1011
Provider Business Practice Location Address Fax Number:
866-337-2677
Provider Enumeration Date:
09/19/2018

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: 175F00000X , with the licence number:  4171 , 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)

  • Identifier: 500767312 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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