Basic Information
| Provider Information | |||||||||
| NPI: | 1619377785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUPPLEMENTAL HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 SW HUNZIKER, SUITE 203 | ||||||||
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| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972232301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883171019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7320 SW HUNZIKER ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972232301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883171019 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | DEVYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COTA | ||||||||
| AuthorizedOfficialTelephone: | 5209757573 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 314621 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 314621 | 05 | OR | MEDICAID |