Healthcare Provider Details

I. General information

NPI: 1104813393
Provider Name (Legal Business Name): CAROL E SWEENEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 NW 29TH ST
CORVALLIS OR
97330-3516
US

IV. Provider business mailing address

2865 NW 29TH ST
CORVALLIS OR
97330-3516
US

V. Phone/Fax

Practice location:
  • Phone: 541-752-0083
  • Fax: 541-752-9624
Mailing address:
  • Phone: 541-752-0083
  • Fax: 541-752-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0331
License Number StateOR

VIII. Authorized Official

Name: CAROL E SWEENEY
Title or Position: OWNER
Credential: P.T.
Phone: 541-752-0083