1831606607 NPI number — ERIKA BUCKLES ATC

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 1831606607 NPI number — ERIKA BUCKLES ATC

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CREMEEN
Provider Other First Name:
ERIKA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831606607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14829 SW MILLIKAN WAY APT 1015
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97003-5495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-876-7420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 SW HALL ST.
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:
97201-9720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-725-4073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2018

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: 204C00000X , with the licence number:  AT-AT-10171402 , 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)

  • Identifier: AT-AT-10171402 . This is a "OREGON HEALTH LICENSING" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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