Provider Demographics
NPI:1689819773
Name:INFRARED BREAST HEALTH,LLC
Entity Type:Organization
Organization Name:INFRARED BREAST HEALTH,LLC
Other - Org Name:INGRID L. EDSTROM, FNP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:LARGE
Authorized Official - Last Name:EDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP,MED,BSN, CITT
Authorized Official - Phone:541-302-2977
Mailing Address - Street 1:1102 HODSON LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2944
Mailing Address - Country:US
Mailing Address - Phone:541-302-2977
Mailing Address - Fax:541-302-6565
Practice Address - Street 1:1102 HODSON LN
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2944
Practice Address - Country:US
Practice Address - Phone:541-302-2977
Practice Address - Fax:541-302-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550045-NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269858Medicaid
OR269858Medicaid
ORR132760Medicare PIN