Healthcare Provider Details

I. General information

NPI: 1295307486
Provider Name (Legal Business Name): CAROLYN RAE CLONTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 NW HARRIMAN STREET
BEND OR
97703-7565
US

IV. Provider business mailing address

1130 NW HARRIMAN ST
BEND OR
97703-1977
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7500
  • Fax: 541-322-7565
Mailing address:
  • Phone: 541-322-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number1295307486
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: