Basic Information
| Provider Information | |||||||||
| NPI: | 1609489459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELAZCO | ||||||||
| FirstName: | KAI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 25TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015084 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4515 SUNNYSIDE RD SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973023954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033708284 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2020 | ||||||||
| LastUpdateDate: | 08/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201909971RN | OR | Y | Nursing Service Providers | Registered Nurse |
No ID Information.