1730181926 NPI number — MERRILL CLINIC

Table of content: (NPI 1730181926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730181926 NPI number — MERRILL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRILL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE BONANZA CLINIC
Provider Other Organization Name Type Code:
3
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:
1730181926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31863 HWY 70
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONANZA
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97623-0440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-545-1820
Provider Business Mailing Address Fax Number:
541-545-1822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31863 HWY 70
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONANZA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97623-0440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-545-1820
Provider Business Practice Location Address Fax Number:
541-545-1822
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHEETS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
AARON
Authorized Official Title or Position:
OWNER OPERATOR
Authorized Official Telephone Number:
541-545-1820

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  93006519 , 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: R162513 . This is a "MEDICARE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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