Healthcare Provider Details

I. General information

NPI: 1134604606
Provider Name (Legal Business Name): STAYTON FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E ASH ST
LEBANON OR
97355-3317
US

IV. Provider business mailing address

1881 W WASHINGTON ST
STAYTON OR
97383-9511
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2641
  • Fax: 503-769-3797
Mailing address:
  • Phone: 503-400-6140
  • Fax: 503-769-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LANCE BRANDON LARGE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 503-400-6140