Provider Demographics
NPI:1619377785
Name:SUPPLEMENTAL HEALTHCARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:DEVYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-975-7573
Mailing Address - Street 1:7320 SW HUNZIKER, SUITE 203
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2301
Mailing Address - Country:US
Mailing Address - Phone:888-317-1019
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER ST STE 203
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:888-317-1019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR314621224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR314621Medicaid