Provider Demographics
NPI:1083361877
Name:NEELY, DAVID C II
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:NEELY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SUBLIMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97385-9505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SUBLIMITY
Practice Address - State:OR
Practice Address - Zip Code:97385-9505
Practice Address - Country:US
Practice Address - Phone:971-218-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDZ742290Medicaid