Provider Demographics
NPI:1689739310
Name:PEDIATRIC SPECIALISTS OF PENDLETON, LLC
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALISTS OF PENDLETON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:GUENTHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-276-0250
Mailing Address - Street 1:1600 SE COURT PL
Mailing Address - Street 2:SUITE, L01
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-3281
Mailing Address - Country:US
Mailing Address - Phone:541-276-0250
Mailing Address - Fax:541-276-0253
Practice Address - Street 1:1600 SE COURT PL
Practice Address - Street 2:SUITE, L01
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3281
Practice Address - Country:US
Practice Address - Phone:541-276-0250
Practice Address - Fax:541-276-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11027630261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288044Medicaid