1730121401 NPI number — SALEM ENDOSCOPY CENTER, LLC

Table of content: JENNIFER R. PENROSE CRNP (NPI 1437449501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730121401 NPI number — SALEM ENDOSCOPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM ENDOSCOPY CENTER, 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:
1730121401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 OAK ST SE
Provider Second Line Business Mailing Address:
SUITE 3095
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-3975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-561-8170
Provider Business Mailing Address Fax Number:
503-561-8167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 OAK ST SE
Provider Second Line Business Practice Location Address:
SUITE 3095
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-3975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-561-8170
Provider Business Practice Location Address Fax Number:
503-561-8167
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WENDOLOWSKI
Authorized Official First Name:
ZOE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
NURSE ADMINISTRATOR
Authorized Official Telephone Number:
503-561-8170

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  071573 , 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: 005765 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00280629 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 102447500 . This is a "REGENCE BCBS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: P356301 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 339145 . This is a "PROVIDENCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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