Healthcare Provider Details

I. General information

NPI: 1184784332
Provider Name (Legal Business Name): PAULINA PEAK FAMILY HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51384 HIGHWAY 97
LA PINE OR
97739-9871
US

IV. Provider business mailing address

PO BOX 3389
LA PINE OR
97739-3389
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-8060
  • Fax:
Mailing address:
  • Phone: 541-536-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200250124NP
License Number StateOR

VIII. Authorized Official

Name: GREGORY L MILLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 541-536-8060