Healthcare Provider Details

I. General information

NPI: 1457703241
Provider Name (Legal Business Name): HALE MEN'S CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 OAK ST SUITE 101
EUGENE OR
97401-4604
US

IV. Provider business mailing address

1410 OAK ST SUITE 101
EUGENE OR
97401-4604
US

V. Phone/Fax

Practice location:
  • Phone: 541-228-3660
  • Fax: 541-228-3670
Mailing address:
  • Phone: 541-228-3660
  • Fax: 541-228-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier123027690
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREGON REGISTRY

VIII. Authorized Official

Name: KRISTIAN M FERRY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 541-228-3660