Healthcare Provider Details

I. General information

NPI: 1679719983
Provider Name (Legal Business Name): GENELL C SNYDER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVEUNE SUITE 1109
PORTLAND OR
97205
US

IV. Provider business mailing address

511 SW 10TH AVE SUITE 1109
PORTLAND OR
97205-2732
US

V. Phone/Fax

Practice location:
  • Phone: 503-888-2979
  • Fax:
Mailing address:
  • Phone: 503-888-2979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6360
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: