Provider Demographics
NPI:1376207977
Name:REBECCA PODHORA LICENSED LIMITED CORPORATION
Entity Type:Organization
Organization Name:REBECCA PODHORA LICENSED LIMITED CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PODHORA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:541-233-7735
Mailing Address - Street 1:8081 NW SAGEBRUSH LN
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-8306
Mailing Address - Country:US
Mailing Address - Phone:541-233-7735
Mailing Address - Fax:541-566-7633
Practice Address - Street 1:190 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1820
Practice Address - Country:US
Practice Address - Phone:541-233-7735
Practice Address - Fax:541-566-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-29
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty