=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730252487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J C PITTS ENTERPRISES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 SW 19TH STREET
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-3198
-----------------------------------------------------
Fax | 208-377-9455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 SW 19TH STREET
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-3198
-----------------------------------------------------
Fax | 208-377-9455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/OWNER
-----------------------------------------------------
Name | JACOB MONG
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 208-377-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 071506ASC
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------