=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437250461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRAGON INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12035 NE GLENN WIDING DR
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-9050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-253-8984
-----------------------------------------------------
Fax | 503-253-2094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20458
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97294-0458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-253-8984
-----------------------------------------------------
Fax | 503-253-2094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MEREDITH JOHANSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-253-8984
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------