Provider Demographics
NPI:1619345501
Name:REESE FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:REESE FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRCTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RIK
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-255-3905
Mailing Address - Street 1:PO BOX 40386
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-0060
Mailing Address - Country:US
Mailing Address - Phone:541-255-0395
Mailing Address - Fax:541-357-5527
Practice Address - Street 1:1755 COBURG RD
Practice Address - Street 2:BLDG 6B
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4982
Practice Address - Country:US
Practice Address - Phone:541-255-3905
Practice Address - Fax:541-357-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044854Medicaid
ORR121325Medicare PIN