Provider Demographics
NPI:1558120428
Name:OREGON COAST MIND AND BODY, LLC
Entity Type:Organization
Organization Name:OREGON COAST MIND AND BODY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:541-236-2088
Mailing Address - Street 1:137 HALL AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1519
Mailing Address - Country:US
Mailing Address - Phone:541-236-2088
Mailing Address - Fax:541-931-8824
Practice Address - Street 1:137 HALL AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1519
Practice Address - Country:US
Practice Address - Phone:541-236-2088
Practice Address - Fax:541-931-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty