Provider Demographics
NPI:1720330533
Name:FARIS, BROOKS BRIASSON II
Entity type:Individual
Prefix:
First Name:BROOKS
Middle Name:BRIASSON
Last Name:FARIS
Suffix:II
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 1:3806 SE IVON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1649
Mailing Address - Country:US
Mailing Address - Phone:503-730-5018
Mailing Address - Fax:
Practice Address - Street 1:1070 NW MURRAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5568
Practice Address - Country:US
Practice Address - Phone:503-644-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19135225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist