Healthcare Provider Details

I. General information

NPI: 1942753231
Provider Name (Legal Business Name): VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number09277
License Number StateOR

VIII. Authorized Official

Name: MS. LAURA HACKETT
Title or Position: PHYSICAL MEDICINE AND REHAB
Credential: MSOTR/L
Phone: 541-826-2111