Provider Demographics
NPI:1649392366
Name:CENTRAL OREGON REGIONAL PATHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:CENTRAL OREGON REGIONAL PATHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-382-7696
Mailing Address - Street 1:1348 NE CUSHING DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3876
Mailing Address - Country:US
Mailing Address - Phone:541-382-7696
Mailing Address - Fax:541-389-5723
Practice Address - Street 1:1348 NE CUSHING DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3876
Practice Address - Country:US
Practice Address - Phone:541-382-7696
Practice Address - Fax:541-389-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D0656805246QC2700X, 246QH0600X, 246R00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246QC2700XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyCytotechnologyGroup - Multi-Specialty
No246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistologyGroup - Multi-Specialty
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR346OtherSTATE LAB LICENSE NUMBER
OR38D0656805OtherCLIA
OR227834Medicaid
OR227834Medicaid
OR220032645Medicare PIN