1649392366 NPI number — CENTRAL OREGON REGIONAL PATHOLOGY SERVICES, LLC

Table of content: (NPI 1649392366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649392366 NPI number — CENTRAL OREGON REGIONAL PATHOLOGY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL OREGON REGIONAL PATHOLOGY SERVICES, 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:
1649392366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1348 NE CUSHING DR
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-3876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-382-7696
Provider Business Mailing Address Fax Number:
541-389-5723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1348 NE CUSHING DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-3876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-382-7696
Provider Business Practice Location Address Fax Number:
541-389-5723
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNGER
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
541-382-7696

Provider Taxonomy Codes

  • Taxonomy code: 246QC2700X , with the licence number:  38D0656805 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246QH0600X , with the licence number: 38D0656805 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246R00000X , with the licence number: 38D0656805 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 38D0656805 , 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: 346 . This is a "STATE LAB LICENSE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 38D0656805 . This is a "CLIA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 227834 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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