Provider Demographics
NPI:1114631322
Name:WINDING WATERS MEDICAL CLINIC
Entity Type:Organization
Organization Name:WINDING WATERS MEDICAL CLINIC
Other - Org Name:WALLOWA PHARMACY OF WINDING WATERS
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KELI
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-426-4502
Mailing Address - Street 1:603 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:
Practice Address - Street 1:605 W HWY 82
Practice Address - Street 2:
Practice Address - City:WALLOWA
Practice Address - State:OR
Practice Address - Zip Code:97885-7114
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINDING WATERS MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-11
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy