Healthcare Provider Details

I. General information

NPI: 1316555428
Provider Name (Legal Business Name): CHETCO MEDICAL & AESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97825 SHOPPING CENTER AVE
BROOKINGS OR
97415-9403
US

IV. Provider business mailing address

PO BOX 2742
BROOKINGS OR
97415-0326
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-9800
  • Fax: 541-412-9300
Mailing address:
  • Phone: 541-412-9800
  • Fax: 541-412-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PALAK J PATEL
Title or Position: PARTNER
Credential: MD
Phone: 541-412-9800