Healthcare Provider Details

I. General information

NPI: 1710174974
Provider Name (Legal Business Name): PORTLAND VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NE MARKET DRIVE
FAIRVIEW OR
97024-9998
US

IV. Provider business mailing address

PO BOX 94414
CLEVELAND OH
44101-4414
US

V. Phone/Fax

Practice location:
  • Phone: 702-341-3164
  • Fax:
Mailing address:
  • Phone: 702-341-3164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579