Healthcare Provider Details

I. General information

NPI: 1891569505
Provider Name (Legal Business Name): CORVALLIS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 NE WEST DEVILS LAKE RD
LINCOLN CITY OR
97367-5131
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1268
  • Fax:
Mailing address:
  • Phone: 541-754-1374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. JAMES KAECH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 541-754-1374