Healthcare Provider Details

I. General information

NPI: 1023094307
Provider Name (Legal Business Name): ROSEBURG CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W HARVARD AVE
ROSEBURG OR
97471-2608
US

IV. Provider business mailing address

2750 W HARVARD AVE
ROSEBURG OR
97471-2608
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-8988
  • Fax: 541-672-8103
Mailing address:
  • Phone: 541-673-8988
  • Fax: 541-672-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DELL G GRAY
Title or Position: CEO
Credential: MA
Phone: 541-673-8988