1134342538 NPI number — SNELL FONTUS, MD, LLC

Table of content: (NPI 1134342538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134342538 NPI number — SNELL FONTUS, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNELL FONTUS, MD, LLC
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:
1134342538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10882
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97440-2882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-684-4716
Provider Business Mailing Address Fax Number:
541-683-9790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1053 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-684-4716
Provider Business Practice Location Address Fax Number:
541-683-9790
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FONTUS
Authorized Official First Name:
SNELL
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
541-684-4716

Provider Taxonomy Codes

  • Taxonomy code: 2086S0127X , with the licence number:  MD20286 , 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: 086108 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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