=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417269465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID VALLEY MEDICAL HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2010
-----------------------------------------------------
Last Update Date | 05/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 198 COMMERCIAL ST SE SUITE 210
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-3489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-485-0710
-----------------------------------------------------
Fax | 503-485-3208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2995 RYAN DRIVE SE SUITE 110
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-485-0710
-----------------------------------------------------
Fax | 503-485-3208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | VERONICA FEATHERSTONE SHEFFIELD
-----------------------------------------------------
Credential | MS BSN RN
-----------------------------------------------------
Telephone | 503-485-0710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 13-1390
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------