=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316017312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS M COZZOCREA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 02/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9370 SW GREENBURG RD SUITE N
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97223-5442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-977-9975
-----------------------------------------------------
Fax | 503-506-5013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9370 SW GREENBURG ROAD SUITE N
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-977-9975
-----------------------------------------------------
Fax | 503-506-5013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00002538
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5688
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------