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General NPI Number Information
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NPI Number | 1912462144
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Entity Type | Organization
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Legal Business Name | EARTH SONG MEDICAL PRACTICE LLC
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Dates
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Enumeration Date | 02/01/2019
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Last Update Date | 02/01/2019
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Provider Practice Location Address
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Address Line | 18173 REDWOOD HWY
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City | SELMA
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State | OR
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Zip | 97538
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Country | US
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Telephone | 541-237-4470
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Fax |
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Provider Business Mailing Address
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Address Line | 4567 DEER CREEK RD
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City | SELMA
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State | OR
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Zip | 97538-9612
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Country | US
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Telephone | 541-237-4470
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MICHAEL G PRUNER
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Credential | ANP-BC
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Telephone | 541-237-4470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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