1659429249 NPI number — ASHLAND INTEGRATIVE CARE PC

Table of content: (NPI 1659429249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659429249 NPI number — ASHLAND INTEGRATIVE CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHLAND INTEGRATIVE CARE PC
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:
1659429249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-0058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-201-3173
Provider Business Mailing Address Fax Number:
561-427-1393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 SISKIYOU BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-2125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-201-3173
Provider Business Practice Location Address Fax Number:
561-427-1393
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRUBER
Authorized Official First Name:
JOANN
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-201-3173

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  201050217 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 201050218 , 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: 500685278 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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