=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790088862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH C PROVENCIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2010
-----------------------------------------------------
Last Update Date | 12/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 NE QUIMBY AVE
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97701-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-382-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 NE QUIMBY AVE
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97701-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-382-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174M00000X
-----------------------------------------------------
Taxonomy Name | Veterinarian
-----------------------------------------------------
License Number | 5796
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------