MEDICARE: JUNIPER RIDGE DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS

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	363LP0200X	Pediatric Nurse Practitioner		OR

General Provider Information

NPI Number	:	1225382617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUNIPER RIDGE DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS

Provider Business Mailing Address
First Line	:	2275 NE DOCTORS DR
Second Line	:	SUITE 1
City	:	BEND
State	:	OR
Zip	:	97701-6324
Country	:	US
Telephone Number	:	541-323-5515
Fax Number	:

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	:	MANAGING MEMBER
Name	:	DR. DEBORAH PADGETT COEHLO
Credential	:	PHD, C-PNP PMHS CFLE
Telephone Number	:	541-323-5515

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	09/09/2019

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