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General NPI Number Information
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NPI Number | 1992999536
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Entity Type | Organization
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Legal Business Name | PACIFIC SPINE & REHAB, LLC
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Dates
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Enumeration Date | 08/28/2007
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Last Update Date | 03/06/2008
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Provider Practice Location Address
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Address Line | 2480 LIBERTY ST NE STE 180
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City | SALEM
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State | OR
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Zip | 97301-8388
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Country | US
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Telephone | 503-364-1990
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Fax | 503-391-4688
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Provider Business Mailing Address
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Address Line | 2480 LIBERTY ST NE STE 180
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City | SALEM
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State | OR
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Zip | 97301-8388
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Country | US
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Telephone | 503-364-1990
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Fax | 503-391-4688
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Authorized Official
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Title or Position | OWNER / MEMBER
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Name | DR. ROBERT D. HEROS
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Credential | M.D.
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Telephone | 503-364-1990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | MD27619
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License Number State | OR
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