=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902615677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEAN MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2025
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4488 NE DEVILS LAKE BLVD
-----------------------------------------------------
City | LINCOLN CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97367-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-614-0407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4488 NE DEVILS LAKE BLVD
-----------------------------------------------------
City | LINCOLN CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97367-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-614-0407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELISA D GARRETT
-----------------------------------------------------
Credential | AGPN
-----------------------------------------------------
Telephone | 541-614-0407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------