Provider Demographics
NPI:1972835445
Name:HARRIS, DALE
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:AUBREY
Other - Middle Name:DALE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 KANE ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-3924
Mailing Address - Country:US
Mailing Address - Phone:541-884-3656
Mailing Address - Fax:
Practice Address - Street 1:900 KANE ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3924
Practice Address - Country:US
Practice Address - Phone:541-884-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR90185145851012D172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker