Healthcare Provider Details

I. General information

NPI: 1225538796
Provider Name (Legal Business Name): PENDLETON FAMILY PRACTICE AND SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 SE DORION AVE
PENDLETON OR
97801-2576
US

IV. Provider business mailing address

202 SE DORION AVE
PENDLETON OR
97801-2576
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-8384
  • Fax: 541-966-8387
Mailing address:
  • Phone: 541-966-8384
  • Fax: 541-966-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDO20295
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberDO20295
License Number StateOR

VIII. Authorized Official

Name: DARLA LINKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-966-8384