Provider Demographics
NPI:1740572221
Name:CENTRAL OREGON CLINICAL GENETICS CENTER, LLC
Entity Type:Organization
Organization Name:CENTRAL OREGON CLINICAL GENETICS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:SCHIRRIPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-749-8196
Mailing Address - Street 1:143 SW SHEVLIN HIXON DR
Mailing Address - Street 2:SUITE #203
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3189
Mailing Address - Country:US
Mailing Address - Phone:541-749-8196
Mailing Address - Fax:541-678-5466
Practice Address - Street 1:143 SW SHEVLIN HIXON DR
Practice Address - Street 2:SUITE #203
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3189
Practice Address - Country:US
Practice Address - Phone:541-749-8196
Practice Address - Fax:541-678-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153157261QH0100X, 261QM2500X
CAA46201291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637292Medicaid
OR500637246Medicaid
OR500637246Medicaid