Provider Demographics
NPI:1043874696
Name:MODERN NOSE CLINIC LLC
Entity Type:Organization
Organization Name:MODERN NOSE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SKARADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-584-1174
Mailing Address - Street 1:340 VISTA AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4546
Mailing Address - Country:US
Mailing Address - Phone:503-584-1174
Mailing Address - Fax:
Practice Address - Street 1:340 VISTA AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4546
Practice Address - Country:US
Practice Address - Phone:503-584-1174
Practice Address - Fax:503-584-1330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN NOSE CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty