Healthcare Provider Details

I. General information

NPI: 1104962067
Provider Name (Legal Business Name): MOUNTAIN MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 NE 3RD ST
BEND OR
97701-4333
US

IV. Provider business mailing address

1302 NE 3RD ST
BEND OR
97701-4333
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-7799
  • Fax: 541-389-4096
Mailing address:
  • Phone: 541-388-7799
  • Fax: 541-389-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALBERT JAMES STONE
Title or Position: OWNER
Credential: MD
Phone: 541-317-0909