Healthcare Provider Details

I. General information

NPI: 1487081394
Provider Name (Legal Business Name): SUSAN D FORDICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 SW OLSON AVE
PENDLETON OR
97801-4421
US

IV. Provider business mailing address

2013 SW OLSON
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-240-1446
  • Fax:
Mailing address:
  • Phone: 541-240-1446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: