Healthcare Provider Details

I. General information

NPI: 1245587674
Provider Name (Legal Business Name): PAIN CONSULTANTS OF OREGON PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S GARDEN WAY STE 101
EUGENE OR
97401-8173
US

IV. Provider business mailing address

360 S GARDEN WAY STE 101
EUGENE OR
97401-8173
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-0149
  • Fax: 541-868-0484
Mailing address:
  • Phone: 541-684-9451
  • Fax: 541-684-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number38D1047176
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JENNIFER WAGNER
Title or Position: ADMINISSTRATOR
Credential:
Phone: 541-684-9451