Provider Demographics
NPI:1679928543
Name:SUMMER WATERS, LLC
Entity Type:Organization
Organization Name:SUMMER WATERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:
Authorized Official - Last Name:COLELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, NTP, CGP
Authorized Official - Phone:541-326-8952
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:BUTTE FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97522-0071
Mailing Address - Country:US
Mailing Address - Phone:541-326-8952
Mailing Address - Fax:
Practice Address - Street 1:832 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7153
Practice Address - Country:US
Practice Address - Phone:541-326-8952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
ORAC01181171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty