1326398595 NPI number — HEATHER BROOK REMAKLUS GREEN B.A.

Table of content: HEATHER BROOK REMAKLUS GREEN B.A. (NPI 1326398595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326398595 NPI number — HEATHER BROOK REMAKLUS GREEN B.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
HEATHER
Provider Middle Name:
BROOK REMAKLUS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.A.
Provider Gender Code:
F

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:
1326398595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14600 NW CORNELL RD
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:
97229-5442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-645-3581
Provider Business Mailing Address Fax Number:
503-629-8517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4941 NE 17TH AVE
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:
97211-5709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-3296
Provider Business Practice Location Address Fax Number:
503-282-3290
Provider Enumeration Date:
09/14/2012

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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