Healthcare Provider Details

I. General information

NPI: 1518521194
Provider Name (Legal Business Name): SOUTH UMPQUA INTEGRATED HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 NE DIVISION ST
MYRTLE CREEK OR
97457-8507
US

IV. Provider business mailing address

PO BOX 3008
MYRTLE CREEK OR
97457-0014
US

V. Phone/Fax

Practice location:
  • Phone: 541-680-9028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
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: DR. MIKE SHIRTCLIFF
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 541-680-9028