Provider Demographics
NPI:1871138453
Name:STARR, KEDRICK
Entity type:Individual
Prefix:
First Name:KEDRICK
Middle Name:
Last Name:STARR
Suffix:
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 1:18417 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-4850
Mailing Address - Country:US
Mailing Address - Phone:208-761-4670
Mailing Address - Fax:
Practice Address - Street 1:14600 NW CORNELL RD.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229
Practice Address - Country:US
Practice Address - Phone:503-645-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator