Provider Demographics
NPI:1790179075
Name:SUPRENANT, BRICE WILLIAM (RD)
Entity Type:Individual
Prefix:MR
First Name:BRICE
Middle Name:WILLIAM
Last Name:SUPRENANT
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 SW RIVER SQ
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-8017
Mailing Address - Country:US
Mailing Address - Phone:304-639-2368
Mailing Address - Fax:
Practice Address - Street 1:16099 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-4680
Practice Address - Country:US
Practice Address - Phone:503-922-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered