1669786174 NPI number — EMILY A LIEUALLEN DO

Table of content: EMILY A LIEUALLEN DO (NPI 1669786174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669786174 NPI number — EMILY A LIEUALLEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEUALLEN
Provider First Name:
EMILY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1669786174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 FORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHN DAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97845-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
475-750-4045
Provider Business Mailing Address Fax Number:
475-754-1585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STRAWBERRY WILDERNESS CLINIC
Provider Second Line Business Practice Location Address:
180 FORD RD.
Provider Business Practice Location Address City Name:
JOHN DAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-575-0404
Provider Business Practice Location Address Fax Number:
541-575-4158
Provider Enumeration Date:
07/27/2010

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: 207Q00000X , with the licence number:  DO164168 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669786174 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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