Healthcare Provider Details

I. General information

NPI: 1952630576
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF PENDLETON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2461 SW PERKINS AVE
PENDLETON OR
97801-4301
US

IV. Provider business mailing address

2461 SW PERKINS AVE
PENDLETON OR
97801-4301
US

V. Phone/Fax

Practice location:
  • Phone: 514-276-0250
  • Fax: 541-276-0253
Mailing address:
  • Phone: 514-276-0250
  • Fax: 541-276-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN PLATT
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-276-0250