1588221691 NPI number — MR. GLEN ALLEN SUCHANEK I CADCI, CRM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588221691 NPI number — MR. GLEN ALLEN SUCHANEK I CADCI, CRM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUCHANEK
Provider First Name:
GLEN
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
CADCI, CRM
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:
1588221691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 NW 6TH AVE
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:
97209-3609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-269-6812
Provider Business Mailing Address Fax Number:
503-208-3186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3811 SE CONCORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97267-3911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-269-6812
Provider Business Practice Location Address Fax Number:
503-208-3186
Provider Enumeration Date:
05/23/2019

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 , with the licence number:  18-07-04 , 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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