=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972013332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UMPQUA HEALTH TRANSITIONAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2017
-----------------------------------------------------
Last Update Date | 10/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 NW MERCY DR STE 330
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-229-7053
-----------------------------------------------------
Fax | 541-459-5741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1813 W HARVARD AVE STE 448
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-957-3094
-----------------------------------------------------
Fax | 541-440-6306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, NETWORK & BUSINESS DEVELOPMENT
-----------------------------------------------------
Name | SUZANNE GOLDBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-464-4079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------