Healthcare Provider Details

I. General information

NPI: 1376342469
Provider Name (Legal Business Name): CASCADE LAKES UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 NE REVERE AVE STE 200
BEND OR
97701-4192
US

IV. Provider business mailing address

431 NE REVERE AVE STE 200
BEND OR
97701-4192
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-7973
  • Fax: 541-508-7968
Mailing address:
  • Phone: 541-508-7973
  • Fax: 541-508-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DENISE CHASE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 541-615-1665