Provider Demographics
NPI:1073819785
Name:TAIT, STUART
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:TAIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 SW MACADAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:503-841-6222
Mailing Address - Fax:
Practice Address - Street 1:5441 SW MACADAM AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6106
Practice Address - Country:US
Practice Address - Phone:503-841-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
OR10054225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No372600000XNursing Service Related ProvidersAdult Companion