=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235666272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY DIRECT HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2017
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 TWIN CREEKS CROSSING LOOP SUITE A
-----------------------------------------------------
City | CENTRAL POINT
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97502-8661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-500-0561
-----------------------------------------------------
Fax | 541-982-7287
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 TWIN CREEKS CROSSING LOOP SUITE A
-----------------------------------------------------
City | CENTRAL POINT
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97502-8661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-500-0561
-----------------------------------------------------
Fax | 541-225-4874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NURSE PRACTITIONER
-----------------------------------------------------
Name | LAURIE B DAHL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 541-500-0561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 201500076NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------