1417529611 NPI number — ROGUE COMMUNITY HEALTH

Table of content: (NPI 1417529611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417529611 NPI number — ROGUE COMMUNITY HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGUE COMMUNITY HEALTH
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:
ROGUE COMMUNITY HEALTH DENTAL CLINIC
Provider Other Organization Name Type Code:
5
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:
1417529611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-7667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-773-3863
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11160 HIGHWAY 62 STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE POINT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97524-8025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-773-3863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WARNKE
Authorized Official First Name:
CALISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
541-842-7642

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 227698 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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