Healthcare Provider Details

I. General information

NPI: 1659331007
Provider Name (Legal Business Name): PACIFIC PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 COUNTRY CLUB RD
EUGENE OR
97401-6019
US

IV. Provider business mailing address

743 COUNTRY CLUB RD
EUGENE OR
97401-6019
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-0878
  • Fax: 541-683-5206
Mailing address:
  • Phone: 541-683-0878
  • Fax: 541-683-5206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberMD13772
License Number StateOR

VIII. Authorized Official

Name: MS. LOIS M FONDREN
Title or Position: MANAGER
Credential: MBA
Phone: 541-683-0878