Provider Demographics
NPI:1275874091
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:KOSAR
Authorized Official - Middle Name:SAAD
Authorized Official - Last Name:MEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EFDA EFODA
Authorized Official - Phone:503-688-4601
Mailing Address - Street 1:4302 SW VACUNA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7105 SW HAMPTON ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8314
Practice Address - Country:US
Practice Address - Phone:503-684-9274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR120925126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty