Provider Demographics
NPI:1356806095
Name:NEVAREZ, LUIZ ALEJANDRO
Entity type:Individual
Prefix:
First Name:LUIZ
Middle Name:ALEJANDRO
Last Name:NEVAREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 SE 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4811
Mailing Address - Country:US
Mailing Address - Phone:503-477-8720
Mailing Address - Fax:
Practice Address - Street 1:5424 SE 82ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4811
Practice Address - Country:US
Practice Address - Phone:503-477-8720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist