1225564180 NPI number — REGINAL STROUGHTER CRM, CGAC1, CADC1 AP

Table of content: REGINAL STROUGHTER CRM, CGAC1, CADC1 AP (NPI 1225564180)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225564180 NPI number — REGINAL STROUGHTER CRM, CGAC1, CADC1 AP

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
STROUGHTER

Provider First Name:
REGINAL

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
CRM, CGAC1, CADC1 AP

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:
1225564180

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
09/25/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10564 SE WASHINGTON 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:
97216-2809

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
503-888-6065

Provider Business Mailing Address Fax Number:
503-228-9558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5257 NE MARTIN LUTHER KING JR STE 201

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
PORTLAND

Provider Business Practice Location Address State Name:
OR

Provider Business Practice Location Address Postal Code:
97211-3283

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
503-676-3710

Provider Business Practice Location Address Fax Number:
503-430-5403

Provider Enumeration Date:
05/11/2017

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: "N" .

Taxonomy code: 101YA0400X , with the licence number: 12-CRM-046 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .