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NPI Code Detail

MEDICARE: MRS. DEANNE HILDE CARLISLE RD, MBA, LD

MEDICARE: MRS. DEANNE HILDE CARLISLE RD, MBA, LD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian92OR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
192OTHERORLISCENSURE NUMBER
2564008OTHERORCDR

General Provider Information

NPI Number : 1194833681
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DEANNE HILDE CARLISLE RD, MBA, LD
Provider Business Mailing Address
First Line : 6915 SE 68TH CT
Second Line :
City : HILLSBORO
State : OR
Zip : 97123-6133
Country : US
Telephone Number : 503-649-6134
Fax Number :
Provider Business Practice Location Address
First Line : 3710 SW US VETERANS HOSPITAL RD
Second Line :
City : PORTLAND
State : OR
Zip : 97239-2964
Country : US
Telephone Number : 503-220-8262
Fax Number : 503-721-1050
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2006
Last Update Date : 07/08/2007

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