Healthcare Provider Details

I. General information

NPI: 1689918401
Provider Name (Legal Business Name): ELIZABETH ANN IDROGO B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 N ELDORADO AVE
KLAMATH FALLS OR
97601-6418
US

IV. Provider business mailing address

507 INDIO ST
TULELAKE CA
96134-9278
US

V. Phone/Fax

Practice location:
  • Phone: 541-883-1030
  • Fax: 541-884-2338
Mailing address:
  • Phone: 530-640-0925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: