1376634980 NPI number — MRS. SUSAN CARROLL KLEMENHAGEN RD LD

Table of content: MRS. SUSAN CARROLL KLEMENHAGEN RD LD (NPI 1376634980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376634980 NPI number — MRS. SUSAN CARROLL KLEMENHAGEN RD LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEMENHAGEN
Provider First Name:
SUSAN
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376634980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2355 OHIO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-269-8182
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 THOMPSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-269-8182
Provider Business Practice Location Address Fax Number:
541-266-7829
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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