1376856864 NPI number — CORVALLIS NATURAL MEDICINE, INC

Table of content: (NPI 1376856864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376856864 NPI number — CORVALLIS NATURAL MEDICINE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORVALLIS NATURAL MEDICINE, INC
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:
1376856864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 NW CIRCLE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97330-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 NW CIRCLE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97330-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-754-2225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NIXDORF
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
541-754-2225

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC01019 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: 1514 , 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)