Healthcare Provider Details

I. General information

NPI: 1801383138
Provider Name (Legal Business Name): ELLEN PLAIA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 NE NORTON LN
MCMINNVILLE OR
97128-8470
US

IV. Provider business mailing address

961 SW DOVE CT
MCMINNVILLE OR
97128-7094
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-6060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10190941
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: