1972120202 NPI number — MISS ELISSA MICHELLE POILLON CPHT

Table of content: MISS ELISSA MICHELLE POILLON CPHT (NPI 1972120202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972120202 NPI number — MISS ELISSA MICHELLE POILLON CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POILLON
Provider First Name:
ELISSA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CPHT
Provider Gender Code:
F

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:
1972120202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10431 BLACKWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL POINT
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97502-9658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-613-7632
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 ROWE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEELER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97147-0035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-715-2999
Provider Business Practice Location Address Fax Number:
844-715-3299
Provider Enumeration Date:
07/02/2020

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: 183700000X , with the licence number:  CPT-0002057 , 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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