Healthcare Provider Details

I. General information

NPI: 1225865876
Provider Name (Legal Business Name): LA PINE COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51615 BLUEWOOD AVE STE 120
LA PINE OR
97739-9211
US

IV. Provider business mailing address

51600 HUNTINGTON RD # 101
LA PINE OR
97739-8887
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-3435
  • Fax:
Mailing address:
  • Phone: 541-536-3435
  • Fax: 541-536-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIE MANES
Title or Position: COO
Credential:
Phone: 541-536-3435