Provider Demographics
NPI:1083069231
Name:PERVUSHIN, ROMAN (LMT)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:PERVUSHIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PORTWAY AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1284
Mailing Address - Country:US
Mailing Address - Phone:541-406-0849
Mailing Address - Fax:541-716-5274
Practice Address - Street 1:501 PORTWAY AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1284
Practice Address - Country:US
Practice Address - Phone:541-406-0849
Practice Address - Fax:541-716-5274
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR161783Medicare PIN