Healthcare Provider Details

I. General information

NPI: 1295896835
Provider Name (Legal Business Name): MR. RICKEY SAM FAUVOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. RICKEY SAM VETKOS

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 N STOKESBERRY PL STE 102
MERIDIAN ID
83646-1135
US

IV. Provider business mailing address

1939 E BURNSIDE ST
PORTLAND OR
97214-1535
US

V. Phone/Fax

Practice location:
  • Phone: 208-229-3238
  • Fax: 208-880-4245
Mailing address:
  • Phone: 503-233-6141
  • Fax: 503-233-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-916188
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA3089
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: