Healthcare Provider Details

I. General information

NPI: 1053733634
Provider Name (Legal Business Name): OHRC SALEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 COMMERCIAL ST SE
SALEM OR
97302-4310
US

IV. Provider business mailing address

1560 COMMERCIAL ST SE
SALEM OR
97302-4310
US

V. Phone/Fax

Practice location:
  • Phone: 360-816-2958
  • Fax:
Mailing address:
  • Phone: 360-816-2958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY A. WILKEN
Title or Position: AUTHORIZED OFFICIAL
Credential: AUD
Phone: 360-816-2958