Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 516802-89 | OR |
NPI | 1689669624 |
---|---|
Provider Name | Mr. Fredric M Harwin |
First Address | Portland, OR 97210-2859 |
Second Address | Portland, OR 97210-2859 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2005 |
Last Update Date | 24/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01621900001 | REGENCE BCBS DME SUPPLIER (01) | OR |
500605356 | (05) | OR |