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General NPI Number Information
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NPI Number | 1497051320
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Entity Type | Organization
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Legal Business Name | NORTHWEST DIAGNOSTIC SERVICES
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Dates
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Enumeration Date | 02/10/2011
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Last Update Date | 12/09/2013
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Provider Practice Location Address
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Address Line | 2728 W MAIN ST SUITE 121
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City | MEDFORD
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State | OR
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Zip | 97501-2499
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Country | US
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Telephone | 541-622-6088
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Fax | 541-622-6090
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Provider Business Mailing Address
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Address Line | 2728 W MAIN ST SUITE 121
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City | MEDFORD
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State | OR
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Zip | 97501-2499
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Country | US
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Telephone | 541-622-6088
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Fax | 541-622-6090
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Authorized Official
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Title or Position | EXCECUTIVE MANAGER
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Name | JANET HETHERINGTON
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Credential |
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Telephone | 541-622-6088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 12-35846
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License Number State | OR
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