Healthcare Provider Details

I. General information

NPI: 1629410162
Provider Name (Legal Business Name): TALENT CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E MAIN ST
TALENT OR
97540
US

IV. Provider business mailing address

PO BOX 422
TALENT OR
97540-0422
US

V. Phone/Fax

Practice location:
  • Phone: 541-535-9108
  • Fax: 541-535-8809
Mailing address:
  • Phone: 541-535-9108
  • Fax: 541-535-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. MAX E TENSCHER
Title or Position: OPERATIONS MEMBER
Credential: FNP
Phone: 541-535-9108