=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942415450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKINGS HARBOR FAMILY PRACTICE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 09/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97825 SHOPPING CENTER AVE.
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-469-2330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7529
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-0344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-469-2330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | D.O.
-----------------------------------------------------
Name | KENNETH MANUELE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-469-2330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 19106
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------