=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265940308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONARCH MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2018
-----------------------------------------------------
Last Update Date | 09/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 595 SW BLUFF DR STE A
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-1283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-731-5673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 363 HIGH ST
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97401-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | APRYL L SCHMALZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 458-201-2098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------