Healthcare Provider Details

I. General information

NPI: 1467735233
Provider Name (Legal Business Name): ROBERT RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 SW 12TH AVE
PORTLAND OR
97205-2329
US

IV. Provider business mailing address

232 NW 6TH AVE
PORTLAND OR
97209-3609
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-7134
  • Fax:
Mailing address:
  • Phone: 503-200-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: