Healthcare Provider Details

I. General information

NPI: 1659524494
Provider Name (Legal Business Name): STAYTON FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 N 10TH AVE
STAYTON OR
97383-2037
US

IV. Provider business mailing address

1375 N 10TH AVE
STAYTON OR
97383-2037
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2641
  • Fax: 503-769-3797
Mailing address:
  • Phone: 503-769-2641
  • Fax: 503-769-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LANCE B LARGE
Title or Position: OWNER
Credential: MD
Phone: 503-769-2641