1073753372 NPI number — TOMMY LEE HARRIS LMT

Table of content: (NPI 1164436093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073753372 NPI number — TOMMY LEE HARRIS LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
TOMMY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
M

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:
1073753372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38954 PROCTOR BLVD # 397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97055-8039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-804-4621
Provider Business Mailing Address Fax Number:
503-665-3188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
735 SE MOUNT HOOD HWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97080-9280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-804-4621
Provider Business Practice Location Address Fax Number:
503-665-3188
Provider Enumeration Date:
02/26/2009

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: 225700000X , with the licence number:  10077 , 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)