=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679597082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRY WERNER, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 GLASSON WAY SUITE B
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-273-4550
-----------------------------------------------------
Fax | 530-273-1076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4688
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95604-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-273-4550
-----------------------------------------------------
Fax | 530-273-1076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. TERRY SCOTT WERNER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 530-273-4550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | A67230
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------