Provider Demographics
NPI:1326739228
Name:UME CRATER LAKE LLC
Entity Type:Organization
Organization Name:UME CRATER LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-965-9415
Mailing Address - Street 1:624 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3840
Mailing Address - Country:US
Mailing Address - Phone:208-965-9415
Mailing Address - Fax:
Practice Address - Street 1:1094 ROYAL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6138
Practice Address - Country:US
Practice Address - Phone:541-779-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental