Healthcare Provider Details

I. General information

NPI: 1013030444
Provider Name (Legal Business Name): THE FAMILY HEALTH CLINIC OF LAPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16480 WILLIAM FOSS RD
LA PINE OR
97739-9486
US

IV. Provider business mailing address

PO BOX 126
LA PINE OR
97739-0126
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-8012
  • Fax: 541-536-9873
Mailing address:
  • Phone: 541-536-8012
  • Fax: 541-536-9873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRENDA J MOLINA
Title or Position: PRESIDENT
Credential:
Phone: 541-536-8012