1447457452 NPI number — DR. AMI RENEE HALVORSON O.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447457452 NPI number — DR. AMI RENEE HALVORSON O.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HALVORSON

Provider First Name:

AMI

Provider Middle Name:

RENEE

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

O.D.

Provider Gender Code:

F

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:

1447457452

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/19/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 1506

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHEHALIS

Provider Business Mailing Address State Name:

WA

Provider Business Mailing Address Postal Code:

98532-0409

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

360-242-3010

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1331 NW LOVEJOY ST STE 750

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:

97209-3281

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

503-535-2883

Provider Business Practice Location Address Fax Number:

503-535-2887

Provider Enumeration Date:

07/02/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  OD00004138 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: 3218ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: OD4138 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152W00000X , with the licence number: ATI3218 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: G8934638 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: G8934639 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: G8934640 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: G8934636 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 2040883 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 500609625 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
• Identifier: G8934637 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: R177569 . This is a "MEDICARE OR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".