Healthcare Provider Details

I. General information

NPI: 1205305190
Provider Name (Legal Business Name): WHITE OAK MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 05/22/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW MEDICAL LOOP
ROSEBURG OR
97471-1645
US

IV. Provider business mailing address

340 NW MEDICAL LOOP
ROSEBURG OR
97471-1645
US

V. Phone/Fax

Practice location:
  • Phone: 541-464-5907
  • Fax: 541-464-8481
Mailing address:
  • Phone: 541-464-5907
  • Fax: 541-464-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DIANE BOLDUC
Title or Position: PRESIDENT
Credential: MD
Phone: 541-464-5907