MEDICARE: LAKE WOUND CLINIC-KLAMATH FALLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	N/A	OR
2	174400000X	Specialist

General Provider Information

NPI Number	:	1134388713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WOUND CLINIC-KLAMATH FALLS

Provider Business Mailing Address
First Line	:	2850 DAGGETT AVE
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1107
Country	:	US
Telephone Number	:	541-517-5169
Fax Number	:	541-273-1147

Provider Business Practice Location Address
First Line	:	2850 DAGGETT AVE
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1107
Country	:	US
Telephone Number	:	541-517-5169
Fax Number	:	541-273-1147

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. CHERYL M BONGIOVANNI
Credential	:	PHD
Telephone Number	:	541-517-5169

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	06/09/2008

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Directions to “LAKE WOUND CLINIC-KLAMATH FALLS ” Practice Location

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