1881960862 NPI number — RICK DETROYE. L.AC., LLC

Table of content: (NPI 1881960862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881960862 NPI number — RICK DETROYE. L.AC., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICK DETROYE. L.AC., LLC
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:
1881960862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 NE 20TH AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-3094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-484-3513
Provider Business Mailing Address Fax Number:
503-239-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 NE 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232-3094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-484-3513
Provider Business Practice Location Address Fax Number:
503-239-1167
Provider Enumeration Date:
03/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DETROYE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-484-3513

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00389 , 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)