Provider Demographics
NPI:1477051795
Name:HEARTHSIDE MEDICINE FAMILY CARE LLC
Entity Type:Organization
Organization Name:HEARTHSIDE MEDICINE FAMILY CARE LLC
Other - Org Name:HEARTHSIDE MEDICINE FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAVILAH
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:BRODHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:970-275-6108
Mailing Address - Street 1:2947 NE YELLOW RIBBON DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7657
Mailing Address - Country:US
Mailing Address - Phone:970-275-6108
Mailing Address - Fax:
Practice Address - Street 1:205 NW FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2801
Practice Address - Country:US
Practice Address - Phone:541-316-5693
Practice Address - Fax:541-255-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201407546NP-PP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500678393Medicaid