Provider Demographics
NPI:1124412051
Name:COOS CLINIC LLC
Entity Type:Organization
Organization Name:COOS CLINIC LLC
Other - Org Name:COOS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDACCI
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:541-294-0257
Mailing Address - Street 1:PO BOX 1733
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL AVE
Practice Address - Street 2:SUITE 418
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2272
Practice Address - Country:US
Practice Address - Phone:541-294-0257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-28
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care