Provider Demographics
NPI:1275857005
Name:VALENTINE, CARL BRENT (IDMT)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:BRENT
Last Name:VALENTINE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6801
Mailing Address - Country:US
Mailing Address - Phone:503-786-1062
Mailing Address - Fax:
Practice Address - Street 1:4131 SE RIVER DR
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6801
Practice Address - Country:US
Practice Address - Phone:503-786-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians