Provider Demographics
NPI:1952923757
Name:CUMMINGS, JUSTIN
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:CUMMINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JUSTIN
Other - Middle Name:
Other - Last Name:CUMMINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:103 W POWELL BLVD UNIT 1353
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0816
Mailing Address - Country:US
Mailing Address - Phone:505-920-4345
Mailing Address - Fax:
Practice Address - Street 1:10105 N. OSWEGO AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203
Practice Address - Country:US
Practice Address - Phone:505-920-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals