Healthcare Provider Details

I. General information

NPI: 1104553387
Provider Name (Legal Business Name): ROBERT SANDERS CRM-II, PRC, PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 08/06/2022
Certification Date: 08/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 NW FANNING WAY APT 317
GRESHAM OR
97030-5599
US

IV. Provider business mailing address

966 NW FANNING WAY APT 317
GRESHAM OR
97030-5599
US

V. Phone/Fax

Practice location:
  • Phone: 503-496-6584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: