Provider Demographics
NPI:1720502180
Name:PEREDEREY, RUSLAN
Entity Type:Individual
Prefix:
First Name:RUSLAN
Middle Name:
Last Name:PEREDEREY
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 1:3008 SW CHASTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-9613
Mailing Address - Country:US
Mailing Address - Phone:503-757-8529
Mailing Address - Fax:
Practice Address - Street 1:3008 SW CHASTAIN AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-9613
Practice Address - Country:US
Practice Address - Phone:503-572-2293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60760768111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor