Healthcare Provider Details

I. General information

NPI: 1891036554
Provider Name (Legal Business Name): FOURTH DIMENSION CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61148 BENHAM RD
BEND OR
97702-2652
US

IV. Provider business mailing address

61148 BENHAM RD
BEND OR
97702-2652
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-2364
  • Fax: 541-383-2364
Mailing address:
  • Phone: 541-383-2364
  • Fax: 541-383-2364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MICHAEL A LANTZ
Title or Position: DIRECTOR
Credential:
Phone: 541-647-7762