Healthcare Provider Details

I. General information

NPI: 1245872357
Provider Name (Legal Business Name): CASCADE DERMATOLOGY AND AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 VILLAGE PLAZA LOOP STE 100
EUGENE OR
97401-6676
US

IV. Provider business mailing address

PO BOX 5679
EUGENE OR
97405-0679
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-7546
  • Fax: 541-345-5254
Mailing address:
  • Phone: 541-485-7546
  • Fax: 541-345-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
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: DENA M PULLAR
Title or Position: OWNER/MANAGER
Credential:
Phone: 541-485-7546