Basic Information
Provider Information
NPI: 1558915579
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NGUYEN
FirstName: CHLOE
MiddleName: ANH
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4400 NE HALSEY ST
Address2:  
City: PORTLAND
State: OR
PostalCode: 972131545
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 870 S FRONT ST STE 200
Address2:  
City: CENTRAL POINT
State: OR
PostalCode: 975022779
CountryCode: US
TelephoneNumber: 5038936900
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/29/2019
LastUpdateDate: 07/29/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1835P2201XRPH-0016996ORY    

No ID Information.


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