Provider Demographics
NPI: | 1508190661 |
---|---|
Name: | PPC GROUP LLC |
Entity Type: | Organization |
Organization Name: | PPC GROUP LLC |
Other - Org Name: | PREVENTION PLUS CLINIC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SOLE MEMBER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ALISON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ERDE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 541-726-1865 |
Mailing Address - Street 1: | 1800 CENTENNIAL BLVD |
Mailing Address - Street 2: | 6 |
Mailing Address - City: | SPRINGFIELD |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97477-4385 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 541-726-2179 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1800 CENTENNIAL BLVD |
Practice Address - Street 2: | SUITE #6 |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97477-4385 |
Practice Address - Country: | US |
Practice Address - Phone: | 541-726-2179 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-09-22 |
Last Update Date: | 2009-10-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | MD23479 | 261QP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |