Healthcare Provider Details

I. General information

NPI: 1629284740
Provider Name (Legal Business Name): HOWARD MEKEMSON CADCI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

PO BOX 338
GRAND RONDE OR
97347-0338
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-2236
  • Fax: 503-879-5089
Mailing address:
  • Phone: 503-879-2236
  • Fax: 503-879-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number70-03-24
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: