1760875777 NPI number — MISS BECKY COONS CADC I CANDIDATE

Table of content: MISS BECKY COONS CADC I CANDIDATE (NPI 1760875777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760875777 NPI number — MISS BECKY COONS CADC I CANDIDATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COONS
Provider First Name:
BECKY
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CADC I CANDIDATE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTT
Provider Other First Name:
REBEKAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760875777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1027 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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-239-8400
Provider Business Mailing Address Fax Number:
503-269-8407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10362 SW MCDONALD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-624-0312
Provider Business Practice Location Address Fax Number:
503-639-3973
Provider Enumeration Date:
03/16/2015

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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