Provider Demographics
NPI:1457628232
Name:HASKETT, CYRUS DALE JR (LMP)
Entity Type:Individual
Prefix:
First Name:CYRUS
Middle Name:DALE
Last Name:HASKETT
Suffix:JR
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5606
Mailing Address - Country:US
Mailing Address - Phone:503-440-5047
Mailing Address - Fax:
Practice Address - Street 1:227 HOWERTON WAY SE
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9089
Practice Address - Country:US
Practice Address - Phone:503-440-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60246912175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath