Healthcare Provider Details

I. General information

NPI: 1275641862
Provider Name (Legal Business Name): MERLE WEST MEDICAL CENTER INC DBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 CROSBY AVE
KLAMATH FALLS OR
97603-5777
US

IV. Provider business mailing address

2633 CROSBY AVE
KLAMATH FALLS OR
97603-5777
US

V. Phone/Fax

Practice location:
  • Phone: 541-885-2666
  • Fax: 541-885-2618
Mailing address:
  • Phone: 541-885-2666
  • Fax: 541-885-2618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number0700001687
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier05957500
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBCBS REENCE
# 2
Identifier152371
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 3
IdentifierH1814 04
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerPACIFIC SOURCE HEALTH PLA

VIII. Authorized Official

Name: MR. STEPHEN ANDREW RYBOLT
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 541-883-6150