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General NPI Number Information
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NPI Number | 1851825566
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Entity Type | Organization
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Legal Business Name | MODERN NOSE CLINIC LLC
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Dates
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Enumeration Date | 04/19/2017
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Last Update Date | 05/02/2022
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Provider Practice Location Address
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Address Line | 340 VISTA AVE SE STE 100
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City | SALEM
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State | OR
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Zip | 97302
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Country | US
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Telephone | 503-584-1174
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Fax | 503-584-1330
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Provider Business Mailing Address
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Address Line | 340 VISTA AVE SE STE 100
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City | SALEM
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State | OR
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Zip | 97302
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Country | US
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Telephone | 503-584-1174
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Fax | 503-584-1330
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DOUGLAS J SKARADA
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Credential | MD
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Telephone | 503-584-1174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 23186
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number |
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License Number State |
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