Healthcare Provider Details

I. General information

NPI: 1659741585
Provider Name (Legal Business Name): STEPHANIE BEDOLLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SW FRAZER AVE STE 282
PENDLETON OR
97801-0048
US

IV. Provider business mailing address

PO BOX 261
BOARDMAN OR
97818-0261
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-6330
  • Fax: 541-278-5419
Mailing address:
  • Phone: 541-481-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: