Healthcare Provider Details

I. General information

NPI: 1881638500
Provider Name (Legal Business Name): ONTARIO VA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SOUTHWEST 3RD
ONTARIO OR
97914
US

IV. Provider business mailing address

20 SOUTHWEST 3RD
ONTARIO OR
97914
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1303
  • Fax: 208-422-1157
Mailing address:
  • Phone: 208-422-1303
  • Fax: 208-422-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA MAYERICK
Title or Position: DIRECTOR, BUSINESS DEVELOPMENT
Credential:
Phone: 202-254-0339