Healthcare Provider Details

I. General information

NPI: 1851679583
Provider Name (Legal Business Name): OREGON TRAIL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 SW CHANDLER AVE 260
BEND OR
97702-3236
US

IV. Provider business mailing address

1693 SW CHANDLER AVE 260
BEND OR
97702-3236
US

V. Phone/Fax

Practice location:
  • Phone: 800-909-9220
  • Fax: 801-665-1882
Mailing address:
  • Phone: 800-909-9220
  • Fax: 801-665-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROB MILLER
Title or Position: FRANCHISEE
Credential:
Phone: 800-909-9220