Healthcare Provider Details

I. General information

NPI: 1679928543
Provider Name (Legal Business Name): SUMMER WATERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 E MAIN ST SUITE 3
MEDFORD OR
97504-7153
US

IV. Provider business mailing address

PO BOX 71
BUTTE FALLS OR
97522-0071
US

V. Phone/Fax

Practice location:
  • Phone: 541-326-8952
  • Fax:
Mailing address:
  • Phone: 541-326-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01181
License Number StateOR

VIII. Authorized Official

Name: MS. SUMMER COLELLA
Title or Position: MEMBER MANAGER
Credential: LAC, NTP, CGP
Phone: 541-326-8952