1326747452 NPI number — RENATA CHALUKIAN PEER SUPPORT

Table of content: RENATA CHALUKIAN PEER SUPPORT (NPI 1326747452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326747452 NPI number — RENATA CHALUKIAN PEER SUPPORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHALUKIAN
Provider First Name:
RENATA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PEER SUPPORT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLER,HOLDEN,AGEE,KOENIG
Provider Other First Name:
RENATA
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:
1326747452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 TURNER RD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97302-2005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
458-203-9321
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1280 CENTER ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-507-4992
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2023

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: 175T00000X , with the licence number:  22-CRM-1480 , 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)





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