Provider Demographics
NPI:1407090608
Name:PREMRO, RICK KEVIN
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:KEVIN
Last Name:PREMRO
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:PO BOX 66500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6500
Mailing Address - Country:US
Mailing Address - Phone:503-657-8663
Mailing Address - Fax:503-723-3180
Practice Address - Street 1:6925 216TH ST SW STE P
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7358
Practice Address - Country:US
Practice Address - Phone:503-657-8663
Practice Address - Fax:503-723-3180
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WART00005682247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist