1063971216 NPI number — LAURIE ANN ERICKSON T.H.W & M.A.I.S.

Table of content: MRS. ARLENE MARIE WALSTON (NPI 1699019836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063971216 NPI number — LAURIE ANN ERICKSON T.H.W & M.A.I.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
LAURIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
T.H.W & M.A.I.S.
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:
1063971216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3181 SW SAM JACKSON PARK RD. OHSU-CDRC
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:
97239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-494-8060
Provider Business Mailing Address Fax Number:
503-494-5990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CDRC 901 E 18TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-744-6551
Provider Business Practice Location Address Fax Number:
503-346-6918
Provider Enumeration Date:
03/18/2019

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: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3697107 . This is a "OREGON DRIVERS LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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