Healthcare Provider Details

I. General information

NPI: 1104027432
Provider Name (Legal Business Name): SIDNEY CHICHESTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 SW HIGHLAND AVE
REDMOND OR
97756-2500
US

IV. Provider business mailing address

299 SW EWEN ST
PRINEVILLE OR
97754-2131
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-2218
  • Fax: 541-504-1195
Mailing address:
  • Phone: 541-504-2218
  • Fax: 541-504-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number02-07-75
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: