Provider Demographics
NPI:1104944057
Name:HAKES, BRIAN SCOTT (DIETICIAN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:HAKES
Suffix:
Gender:M
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32675 MERRILL LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-8817
Mailing Address - Country:US
Mailing Address - Phone:541-409-6375
Mailing Address - Fax:
Practice Address - Street 1:32675 MERRILL LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-8817
Practice Address - Country:US
Practice Address - Phone:541-409-6375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10158338133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare UPIN
PENDINGMedicare ID - Type Unspecified