Provider Demographics
NPI:1902813884
Name:CENTRAL OREGON ENT LLC - EAR NOSE THROAT AND FACIAL PLASTIC SURGEY
Entity Type:Organization
Organization Name:CENTRAL OREGON ENT LLC - EAR NOSE THROAT AND FACIAL PLASTIC SURGEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:BUSINESS OFFICE
Authorized Official - Phone:541-312-6798
Mailing Address - Street 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7132
Mailing Address - Country:US
Mailing Address - Phone:541-312-6799
Mailing Address - Fax:541-312-7050
Practice Address - Street 1:2450 NE MARY ROSE PL
Practice Address - Street 2:SUITE 120
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7132
Practice Address - Country:US
Practice Address - Phone:541-312-6799
Practice Address - Fax:541-312-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286653Medicaid
109271Medicare ID - Type Unspecified