Healthcare Provider Details

I. General information

NPI: 1659934982
Provider Name (Legal Business Name): EQUINOX CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E 18TH AVE
EUGENE OR
97401-4160
US

IV. Provider business mailing address

160 E 18TH AVE
EUGENE OR
97401-4160
US

V. Phone/Fax

Practice location:
  • Phone: 541-790-2455
  • Fax:
Mailing address:
  • Phone: 206-418-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) 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: RANDALL DOUGLAS KELLY
Title or Position: DMSC PAC
Credential:
Phone: 206-418-8222