Healthcare Provider Details

I. General information

NPI: 1588208300
Provider Name (Legal Business Name): MEMORY KNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 SE FOWLER ST STE 2
ROSEBURG OR
97470-3309
US

IV. Provider business mailing address

283 SE FOWLER ST STE 2
ROSEBURG OR
97470-3309
US

V. Phone/Fax

Practice location:
  • Phone: 541-464-6455
  • Fax: 541-464-6457
Mailing address:
  • Phone: 541-464-6455
  • Fax: 541-464-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: