Provider Demographics
NPI:1790838324
Name:KIDS INTERVENTION & DIAGNOSTIC SERVICE CENTER, INC.
Entity Type:Organization
Organization Name:KIDS INTERVENTION & DIAGNOSTIC SERVICE CENTER, INC.
Other - Org Name:KIDS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:MYRA
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-383-5958
Mailing Address - Street 1:1375 NW KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-2242
Mailing Address - Country:US
Mailing Address - Phone:541-383-5958
Mailing Address - Fax:541-383-3016
Practice Address - Street 1:1375 NW KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2242
Practice Address - Country:US
Practice Address - Phone:541-383-5958
Practice Address - Fax:541-383-3016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR058144Medicaid