Healthcare Provider Details

I. General information

NPI: 1265591010
Provider Name (Legal Business Name): MRS. MARY T. STREETER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3577 HAWTHORNE AVE
EUGENE OR
97402-1917
US

IV. Provider business mailing address

3577 HAWTHORNE AVE
EUGENE OR
97402-1917
US

V. Phone/Fax

Practice location:
  • Phone: 541-688-0460
  • Fax:
Mailing address:
  • Phone: 541-688-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number2011-506306-0711-REL
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2011-506306-0711-REL
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRELATIVE FOSTER CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: