Healthcare Provider Details

I. General information

NPI: 1740572221
Provider Name (Legal Business Name): CENTRAL OREGON CLINICAL GENETICS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 SW SHEVLIN HIXON DR SUITE #203
BEND OR
97702-3189
US

IV. Provider business mailing address

143 SW SHEVLIN HIXON DR SUITE #203
BEND OR
97702-3189
US

V. Phone/Fax

Practice location:
  • Phone: 541-749-8196
  • Fax: 541-678-5466
Mailing address:
  • Phone: 541-749-8196
  • Fax: 541-678-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMD153157
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD153157
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberA46201
License Number StateCA

VIII. Authorized Official

Name: DR. OSVALDO ANTONIO SCHIRRIPA
Title or Position: DIRECTOR/OWNER
Credential: M.D.
Phone: 541-749-8196