Provider Demographics
NPI:1639503253
Name:SALEM TRAVEL CLINIC, LLC
Entity Type:Organization
Organization Name:SALEM TRAVEL CLINIC, LLC
Other - Org Name:SALEM TRAVEL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIROD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-540-9999
Mailing Address - Street 1:2720 COMMERCIAL ST SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4495
Mailing Address - Country:US
Mailing Address - Phone:503-540-9999
Mailing Address - Fax:503-540-3105
Practice Address - Street 1:2720 COMMERCIAL ST SE
Practice Address - Street 2:SUITE 201
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4495
Practice Address - Country:US
Practice Address - Phone:503-540-9999
Practice Address - Fax:503-540-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12930261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service