Healthcare Provider Details

I. General information

NPI: 1295219731
Provider Name (Legal Business Name): RACHEL ROSE SOURS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10395 NW GLENCOE RD STE 500
NORTH PLAINS OR
97133-8223
US

IV. Provider business mailing address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

V. Phone/Fax

Practice location:
  • Phone: 503-647-2095
  • Fax: 503-647-2096
Mailing address:
  • Phone: 800-328-8602
  • Fax: 952-285-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P10193792
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: