1730535576 NPI number — OAK & PINE FAMILY GROUP

Table of content: (NPI 1730535576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730535576 NPI number — OAK & PINE FAMILY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK & PINE FAMILY GROUP
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:
6
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:
1730535576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1746 W 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97402-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-342-7678
Provider Business Mailing Address Fax Number:
541-342-7223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1746 W 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97402-3710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-342-7678
Provider Business Practice Location Address Fax Number:
541-342-7223
Provider Enumeration Date:
05/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VILLASENOR
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
JOEL
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
541-342-7678

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  HAS-P-10160789 , 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: 500689305 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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