Healthcare Provider Details

I. General information

NPI: 1992942064
Provider Name (Legal Business Name): LESTER TENGSICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10424 SE CHERRY BLOSSOM DR STE F
PORTLAND OR
97216-2825
US

IV. Provider business mailing address

PO BOX 33912
PORTLAND OR
97292-3912
US

V. Phone/Fax

Practice location:
  • Phone: 503-760-5151
  • Fax: 503-760-5454
Mailing address:
  • Phone: 503-760-5151
  • Fax: 503-760-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDP00263
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00263
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDP00263
License Number StateOR

VIII. Authorized Official

Name: LESTER TENGSICO
Title or Position: OWNER
Credential:
Phone: 503-760-5151