Provider Demographics
NPI:1770049710
Name:GREGORY, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GREGORY
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 1:12415 NW HASKELL CT APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3967
Mailing Address - Country:US
Mailing Address - Phone:503-764-8881
Mailing Address - Fax:
Practice Address - Street 1:12415 NW HASKELL CT APT 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-3967
Practice Address - Country:US
Practice Address - Phone:503-764-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information