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General NPI Number Information
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NPI Number | 1669607792
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Entity Type | Organization
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Legal Business Name | NORTH LAKE CLINIC, LLC
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 87520 BAY RD
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City | CHRISTMAS VALLEY
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State | OR
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Zip | 97641-0377
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Country | US
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Telephone | 541-576-2343
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Fax | 541-576-2869
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Provider Business Mailing Address
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Address Line | PO BOX 377
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City | CHRISTMAS VALLEY
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State | OR
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Zip | 97641-0377
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Country | US
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Telephone | 541-576-2343
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Fax | 541-576-2869
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRUCE D CARLSON
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Credential | M.D.
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Telephone | 541-576-2343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | MD07786
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License Number State | OR
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