Healthcare Provider Details

I. General information

NPI: 1265484364
Provider Name (Legal Business Name): MADELYN JO KOONTZ RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 BEVERLY AVE NE
SALEM OR
97305-1349
US

IV. Provider business mailing address

3030 LAWNRIDGE ST SW
ALBANY OR
97321-3444
US

V. Phone/Fax

Practice location:
  • Phone: 503-363-6065
  • Fax: 503-585-3523
Mailing address:
  • Phone: 541-926-9216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number24
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: