Healthcare Provider Details

I. General information

NPI: 1790450138
Provider Name (Legal Business Name): OMAR FLORES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 NE FOURTH PLAIN BLVD
VANCOUVER WA
98661-6830
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-0502
  • Fax: 206-764-0516
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberGARCIO107MC
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: