Healthcare Provider Details

I. General information

NPI: 1356586374
Provider Name (Legal Business Name): MRS. PEGGY JEANINE GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3692 HICKORY AVE
EUGENE OR
97401-5306
US

IV. Provider business mailing address

3692 HICKORY AVE
EUGENE OR
97401-5306
US

V. Phone/Fax

Practice location:
  • Phone: 514-284-7800
  • Fax: 514-284-7804
Mailing address:
  • Phone: 514-284-7800
  • Fax: 514-284-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
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:
Title or Position:
Credential:
Phone: