1114262284 NPI number — THREE BRANCHES CLINIC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114262284 NPI number — THREE BRANCHES CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE BRANCHES CLINIC PC
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:
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:
1114262284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-267-2142
Provider Business Mailing Address Fax Number:
541-267-2073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-267-2142
Provider Business Practice Location Address Fax Number:
541-267-2073
Provider Enumeration Date:
11/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BRANSON
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
SECRETARY/MASSAGE THERAPIST
Authorized Official Telephone Number:
541-267-2142

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00216 , 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)





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