Healthcare Provider Details

I. General information

NPI: 1720502180
Provider Name (Legal Business Name): RUSLAN PEREDEREY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 SW CHASTAIN AVE
GRESHAM OR
97080-9613
US

IV. Provider business mailing address

3008 SW CHASTAIN AVE
GRESHAM OR
97080-9613
US

V. Phone/Fax

Practice location:
  • Phone: 503-572-2293
  • Fax:
Mailing address:
  • Phone: 503-757-8529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60760768
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: