Provider Demographics
NPI:1003210600
Name:DR ANNA LLC
Entity Type:Organization
Organization Name:DR ANNA LLC
Other - Org Name:CANYONVILLE HEALTH AND URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBACA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-391-4053
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0888
Mailing Address - Country:US
Mailing Address - Phone:541-839-4211
Mailing Address - Fax:541-839-4983
Practice Address - Street 1:115 S PINE ST
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9648
Practice Address - Country:US
Practice Address - Phone:541-839-4211
Practice Address - Fax:541-839-4983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26035207R00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR141355OtherMEDICARE