Healthcare Provider Details

I. General information

NPI: 1679781686
Provider Name (Legal Business Name): WARM SPRINGS HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 KOTNUM ROAD
WARM SPRINGS OR
97761-1209
US

IV. Provider business mailing address

P.O. BOX 1209
WARM SPRINGS OR
97761-1209
US

V. Phone/Fax

Practice location:
  • Phone: 541-553-1196
  • Fax: 541-553-1130
Mailing address:
  • Phone: 541-553-1196
  • Fax: 541-553-1130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number758
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier758
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerSTATE OF ALASKA MEDICAL LICENSE

VIII. Authorized Official

Name: MRS. RANEVA JUNE DOWTY
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 541-553-1196