Healthcare Provider Details

I. General information

NPI: 1215732813
Provider Name (Legal Business Name): CARRIE R LUKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 3
PENDLETON OR
97801-3971
US

IV. Provider business mailing address

1100 SOUTHGATE STE 3
PENDLETON OR
97801-3971
US

V. Phone/Fax

Practice location:
  • Phone: 541-215-4440
  • Fax: 541-429-4118
Mailing address:
  • Phone: 541-215-4440
  • Fax: 541-429-4118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. TYLER PATRICK JOHNSON
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 541-215-4440