MEDICARE: DENOVO CENTER, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1952977480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENOVO CENTER, LLC

Provider Business Mailing Address
First Line	:	1863 PIONEER PKWY E # 203
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-3907
Country	:	US
Telephone Number	:	541-556-5652
Fax Number	:

Provider Business Practice Location Address
First Line	:	895 COUNTRY CLUB RD STE A140
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-6028
Country	:	US
Telephone Number	:	541-556-6552
Fax Number	:	541-230-9656

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER/FOUNDER
Name	:	STEPHANIE WAGUESPACK
Credential	:
Telephone Number	:	541-556-5652

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	03/16/2022

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