Basic Information
| Provider Information | |||||||||
| NPI: | 1205446663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | JUNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOHAPPY | ||||||||
| OtherFirstName: | VIVIAN | ||||||||
| OtherMiddleName: | JUNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978010160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412408754 | ||||||||
| Practice Location | |||||||||
| Address1: | 46314 TIMINE WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978019417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412408754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 405300000X | 20-CRM-179 | OR | Y |
No ID Information.