Healthcare Provider Details

I. General information

NPI: 1164109906
Provider Name (Legal Business Name): MCKENZIE RIVER GYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 COBURG RD UNIT 503
EUGENE OR
97401-4900
US

IV. Provider business mailing address

PO BOX 512
WALTERVILLE OR
97489-0512
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-8307
  • Fax:
Mailing address:
  • Phone: 541-505-1802
  • Fax: 541-314-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: EMILY DOWNING-MOORE
Title or Position: OWNER
Credential: CNM/NP
Phone: 541-505-1802