Provider Demographics
NPI:1629410162
Name:TALENT CLINIC, LLC
Entity Type:Organization
Organization Name:TALENT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:E
Authorized Official - Last Name:TENSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-535-9108
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-0422
Mailing Address - Country:US
Mailing Address - Phone:541-535-9108
Mailing Address - Fax:541-535-8809
Practice Address - Street 1:312 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540
Practice Address - Country:US
Practice Address - Phone:541-535-9108
Practice Address - Fax:541-535-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500668536Medicaid
OR500668536Medicaid