Healthcare Provider Details

I. General information

NPI: 1790838324
Provider Name (Legal Business Name): KIDS INTERVENTION & DIAGNOSTIC SERVICE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 NW KINGSTON AVE
BEND OR
97701-2242
US

IV. Provider business mailing address

1375 NW KINGSTON AVE
BEND OR
97701-2242
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-5958
  • Fax: 541-383-3016
Mailing address:
  • Phone: 541-383-5958
  • Fax: 541-383-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier058144
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: BETH MYRA PATTERSON
Title or Position: GENERAL MANAGER
Credential:
Phone: 541-383-5958