Healthcare Provider Details

I. General information

NPI: 1376262824
Provider Name (Legal Business Name): TSEHAY M SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14012 SE RUSK RD
MILWAUKIE OR
97222-3221
US

IV. Provider business mailing address

14012 SE RUSK RD
MILWAUKIE OR
97222-3221
US

V. Phone/Fax

Practice location:
  • Phone: 503-830-7363
  • Fax: 503-908-3601
Mailing address:
  • Phone: 503-830-7363
  • Fax: 503-908-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number528045
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: