1295896835 NPI number — MR. RICKEY SAM FAUVOR

Table of content: MR. RICKEY SAM FAUVOR (NPI 1295896835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295896835 NPI number — MR. RICKEY SAM FAUVOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAUVOR
Provider First Name:
RICKEY
Provider Middle Name:
SAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VETKOS
Provider Other First Name:
RICKEY
Provider Other Middle Name:
SAM
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295896835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1939 E BURNSIDE 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:
97214-1535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-233-6141
Provider Business Mailing Address Fax Number:
503-233-2889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2512 N STOKESBERRY PL STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-229-3238
Provider Business Practice Location Address Fax Number:
208-880-4245
Provider Enumeration Date:
12/13/2006

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: 237700000X , with the licence number:  HAS-P-916188 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: HA3089 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82-3793314 . This is a "INSURANCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 82-3793314 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".