Provider Demographics
NPI:1649837378
Name:KERI NEEDLES
Entity type:Organization
Organization Name:KERI NEEDLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEEDLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-789-9159
Mailing Address - Street 1:21336 SW AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97003-1657
Mailing Address - Country:US
Mailing Address - Phone:503-789-9159
Mailing Address - Fax:
Practice Address - Street 1:2263 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5947
Practice Address - Country:US
Practice Address - Phone:503-789-9159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service