Provider Demographics
NPI:1740971878
Name:RADZHABOV, ABDURAKHMON
Entity type:Individual
Prefix:
First Name:ABDURAKHMON
Middle Name:
Last Name:RADZHABOV
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 1:16940 TRACY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4558
Mailing Address - Country:US
Mailing Address - Phone:551-258-7270
Mailing Address - Fax:
Practice Address - Street 1:16940 TRACY AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4558
Practice Address - Country:US
Practice Address - Phone:551-258-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR519252311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home