Provider Demographics
NPI:1689279184
Name:QUALITY LIFE MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:QUALITY LIFE MEDICAL PRACTICE LLC
Other - Org Name:QUALITY LIFE FAMILY PRACTICE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:541-314-4894
Mailing Address - Street 1:1201 NE 7TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1451
Mailing Address - Country:US
Mailing Address - Phone:541-314-4894
Mailing Address - Fax:
Practice Address - Street 1:1201 NE 7TH ST STE E
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1451
Practice Address - Country:US
Practice Address - Phone:541-314-4894
Practice Address - Fax:541-314-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500642365Medicaid