MEDICARE: JUNIPER RIDGE DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1053757666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUNIPER RIDGE DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	2980 N BEVERLY GLEN CIR
Second Line	:	SUITE 100
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1726
Country	:	US
Telephone Number	:	310-474-9809
Fax Number	:	888-431-8819

Provider Business Practice Location Address
First Line	:	62930 O B RILEY RD STE 300
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-9459
Country	:	US
Telephone Number	:	541-323-5515
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DEBORAH P. COEHLO
Credential	:	NP
Telephone Number	:	541-323-5515

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	09/09/2019

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