Provider Demographics
NPI:1295896835
Name:FAUVOR, RICKEY SAM
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:SAM
Last Name:FAUVOR
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICKEY
Other - Middle Name:SAM
Other - Last Name:VETKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1939 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1535
Mailing Address - Country:US
Mailing Address - Phone:503-233-6141
Mailing Address - Fax:503-233-2889
Practice Address - Street 1:2512 N STOKESBERRY PL STE 102
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1135
Practice Address - Country:US
Practice Address - Phone:208-229-3238
Practice Address - Fax:208-880-4245
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-916188237700000X
IDHA3089237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID82-3793314OtherINSURANCE
ID82-3793314Medicaid