Healthcare Provider Details

I. General information

NPI: 1306623657
Provider Name (Legal Business Name): COQUILLE VALLEY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 8TH ST
MYRTLE POINT OR
97458-1214
US

IV. Provider business mailing address

PO BOX 374
COQUILLE OR
97423-0374
US

V. Phone/Fax

Practice location:
  • Phone: 541-824-0400
  • Fax: 541-592-7497
Mailing address:
  • Phone: 541-396-3101
  • Fax: 541-824-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
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: JEFFREY M LANG
Title or Position: CEO
Credential:
Phone: 541-396-3101