1790959344 NPI number — JUSTINE CRAIG

Table of content: JUSTINE CRAIG (NPI 1790959344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790959344 NPI number — JUSTINE CRAIG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAIG
Provider First Name:
JUSTINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROGERS
Provider Other First Name:
JUSTINE
Provider Other Middle Name:
CRAIG
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790959344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5331 SW MACADAM AVENUE
Provider Second Line Business Mailing Address:
SUITE 258 PMB 419
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-422-8468
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5331 SW MACADAM AVENUE
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-422-8468
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2008

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: 2251X0800X , with the licence number:  2529 , 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)