Healthcare Provider Details

I. General information

NPI: 1902813884
Provider Name (Legal Business Name): CENTRAL OREGON ENT LLC - EAR NOSE THROAT AND FACIAL PLASTIC SURGEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 NE MARY ROSE PL SUITE 120
BEND OR
97701-7132
US

IV. Provider business mailing address

2450 NE MARY ROSE PL SUITE 120
BEND OR
97701-7132
US

V. Phone/Fax

Practice location:
  • Phone: 541-312-6799
  • Fax: 541-312-7050
Mailing address:
  • Phone: 541-312-6799
  • Fax: 541-312-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHELLY L WALDEN
Title or Position: PRACTICE MANAGER
Credential: BUSINESS OFFICE
Phone: 541-312-6798