Healthcare Provider Details

I. General information

NPI: 1053545590
Provider Name (Legal Business Name): CHILOQUIN FAMILY PRACTICE INC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 RANCH RD
CHILOQUIN OR
97624-5749
US

IV. Provider business mailing address

PO BOX 331
CHILOQUIN OR
97624-0331
US

V. Phone/Fax

Practice location:
  • Phone: 541-783-3412
  • Fax: 541-783-3412
Mailing address:
  • Phone: 541-783-3412
  • Fax: 541-783-3412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD18099
License Number StateOR

VIII. Authorized Official

Name: DR. LAWRENCE LEE COHEN
Title or Position: OWNER
Credential: M.D.
Phone: 541-783-3412