Healthcare Provider Details

I. General information

NPI: 1245821255
Provider Name (Legal Business Name): MARY S SCHROCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 NE FORD ST
MCMINNVILLE OR
97128-4608
US

IV. Provider business mailing address

412 NE FORD ST
MCMINNVILLE OR
97128-4608
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-7525
  • Fax:
Mailing address:
  • Phone: 503-434-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number000030858RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: