1629102454 NPI number — MRS. LOIS ELIZABETH YEVDALCIA DIMICK LMT

Table of content: MRS. LOIS ELIZABETH YEVDALCIA DIMICK LMT (NPI 1629102454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629102454 NPI number — MRS. LOIS ELIZABETH YEVDALCIA DIMICK LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIMICK
Provider First Name:
LOIS ELIZABETH
Provider Middle Name:
YEVDALCIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAMARILLO
Provider Other First Name:
LOIS ELIZABETH
Provider Other Middle Name:
YEVDALCIA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629102454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1912 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST GROVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-380-7753
Provider Business Mailing Address Fax Number:
503-359-4760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-380-7753
Provider Business Practice Location Address Fax Number:
503-359-4760
Provider Enumeration Date:
03/15/2007

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: 225700000X , with the licence number:  11715 , 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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