Healthcare Provider Details

I. General information

NPI: 1730554163
Provider Name (Legal Business Name): DAVE FOSBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 NW GREENWOOD AVE
BEND OR
97703-2078
US

IV. Provider business mailing address

414 NE NORTON AVE
BEND OR
97701-4310
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-4293
  • Fax:
Mailing address:
  • Phone: 541-213-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: