Provider Demographics
NPI:1376925719
Name:PREMIER ENDOCRINOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PREMIER ENDOCRINOLOGY ASSOCIATES, LLC
Other - Org Name:PREMIER ENDOCRINOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOARCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-967-4240
Mailing Address - Street 1:700 BELLEVUE ST SE
Mailing Address - Street 2:SUITE #290
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3819
Mailing Address - Country:US
Mailing Address - Phone:503-967-4240
Mailing Address - Fax:503-339-9546
Practice Address - Street 1:960 LIBERTY STREET SE SUITE 170
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-967-4240
Practice Address - Fax:503-339-9546
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER ENDOCRINOLOGY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000451133V00000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR26956Medicaid