Healthcare Provider Details

I. General information

NPI: 1932103363
Provider Name (Legal Business Name): GLASRIDGE VENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 APPLEGATE ST
PHILOMATH OR
97370-9439
US

IV. Provider business mailing address

PO BOX 1359
CORVALLIS OR
97339-1359
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-4834
  • Fax: 541-929-4836
Mailing address:
  • Phone: 541-929-4834
  • Fax: 541-929-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier182484
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: BRIDGETT DAVIS
Title or Position: OWNER
Credential:
Phone: 541-929-4834