MEDICARE: ABDURAKHMON RADZHABOV

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
1	311ZA0620X	Adult Care Home Facility	519252	OR

General Provider Information

NPI Number	:	1740971878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABDURAKHMON RADZHABOV

Provider Business Mailing Address
First Line	:	16940 TRACY AVE
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4558
Country	:	US
Telephone Number	:	551-258-7270
Fax Number	:

Provider Business Practice Location Address
First Line	:	16940 TRACY AVE
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4558
Country	:	US
Telephone Number	:	551-258-7270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2023
Last Update Date	:	05/18/2023

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Directions to “ ABDURAKHMON RADZHABOV ” Practice Location

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