Provider Demographics
NPI:1780634808
Name:ROGUE VALLEY MANOR, INC
Entity Type:Organization
Organization Name:ROGUE VALLEY MANOR, INC
Other - Org Name:ROGUE VALLEY MANOR CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-587-7133
Mailing Address - Street 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-857-7133
Mailing Address - Fax:541-857-7594
Practice Address - Street 1:1200 MIRA MAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8546
Practice Address - Country:US
Practice Address - Phone:541-857-7133
Practice Address - Fax:541-857-7594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROGUE VALLEY MANOR INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114952Medicare PIN