Healthcare Provider Details

I. General information

NPI: 1730772930
Provider Name (Legal Business Name): ERIC THOR RASDAL PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 11/17/2023
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 ONYX AVE
KLAMATH FALLS OR
97603-7279
US

IV. Provider business mailing address

3206 ONYX AVE
KLAMATH FALLS OR
97603-7279
US

V. Phone/Fax

Practice location:
  • Phone: 541-891-0194
  • Fax:
Mailing address:
  • Phone: 541-891-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW000107296
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: