1699205773 NPI number — CEMENTED ROSE THERAPEUTICS, LLC

Table of content: (NPI 1699205773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699205773 NPI number — CEMENTED ROSE THERAPEUTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEMENTED ROSE THERAPEUTICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1699205773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4110 NE 122ND AVE STE 115
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:
97230-1384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-227-3553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4110 NE 122ND AVE STE 115
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:
97230-1384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-227-3553
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SECRETT
Authorized Official First Name:
SHARNISSA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
BEHAVIORAL HEALTH DIRECTOR
Authorized Official Telephone Number:
971-227-3553

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L6941 , 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)





Copyright © 2007-2025 www.npivalidator.com