Provider Demographics
NPI:1215091400
Name:DETROYE, RICHARD WILLIAM (LAC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIAM
Last Name:DETROYE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 NE 32ND CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3620
Mailing Address - Country:US
Mailing Address - Phone:503-288-2878
Mailing Address - Fax:
Practice Address - Street 1:200 N.E. 20TH AVENUE
Practice Address - Street 2:SUITE 140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-484-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC 00389171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist