Provider Demographics
NPI: | 1811022197 |
---|---|
Name: | VARGOVICH, KATHLEEN M (DC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KATHLEEN |
Middle Name: | M |
Last Name: | VARGOVICH |
Suffix: | |
Gender: | F |
Credentials: | DC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 10245 NE CLACKAMAS ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97220 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-255-4376 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10245 NE CLACKAMAS ST |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97220 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-255-4376 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-02-23 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 273032 | 111N00000X |
WA | 3230 | 111N00000X |
OR | 5324 | 225700000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 111N00000X | Chiropractic Providers | Chiropractor | |
Not Answered | 225700000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | R109461 | Medicare ID - Type Unspecified | |
U84934 | Medicare UPIN |