Healthcare Provider Details

I. General information

NPI: 1639944473
Provider Name (Legal Business Name): MAURICIO JUAREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 COMMERCIAL ST SE
SALEM OR
97302-4682
US

IV. Provider business mailing address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-3533
  • Fax:
Mailing address:
  • Phone: 541-766-0127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0013881
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: