1467018739 NPI number — ACTIVEEDGE TUALATIN, LLP

Table of content: DR. REBECCA RIALON BERRY PH.D. (NPI 1619295185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467018739 NPI number — ACTIVEEDGE TUALATIN, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVEEDGE TUALATIN, LLP
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:
1467018739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2090 TANNER CREEK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LINN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-387-5449
Provider Business Mailing Address Fax Number:
503-342-6846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19150 SW 90TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WEST LINN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-387-5449
Provider Business Practice Location Address Fax Number:
503-387-5449
Provider Enumeration Date:
05/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MORLAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
503-387-5449

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com