1821730417 NPI number — POWERED BY SELF LOVE OREGON

Table of content: (NPI 1821730417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821730417 NPI number — POWERED BY SELF LOVE OREGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWERED BY SELF LOVE OREGON
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:
1821730417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16027 BROOKHURST ST STE I-732
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUNTAIN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92708-1551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
657-321-9765
Provider Business Mailing Address Fax Number:
229-218-2667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5305 RIVER RD N STE B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEIZER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97303-5324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
657-321-9765
Provider Business Practice Location Address Fax Number:
229-218-2667
Provider Enumeration Date:
04/13/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
LOAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
714-880-5065

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)