Healthcare Provider Details

I. General information

NPI: 1023183167
Provider Name (Legal Business Name): HEALTH PRACTITIONER CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 NW 4TH AVE
CANBY OR
97013
US

IV. Provider business mailing address

143 NW 4TH AVE
CANBY OR
97013
US

V. Phone/Fax

Practice location:
  • Phone: 503-263-6611
  • Fax: 503-266-5674
Mailing address:
  • Phone: 503-263-6611
  • Fax: 503-266-5674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000037573N1
License Number StateOR

VIII. Authorized Official

Name: MRS. BETTE GAY SEAGREN
Title or Position: OWNER
Credential: CFNP
Phone: 503-263-6611