Provider Demographics
NPI:1932476421
Name:SOUTHERN OREGON UNIVERSITY
Entity Type:Organization
Organization Name:SOUTHERN OREGON UNIVERSITY
Other - Org Name:STUDENT HEALTH AND WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SHWC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:POTRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-552-6138
Mailing Address - Street 1:1250 SISKIYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 INDIANA ST.
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520
Practice Address - Country:US
Practice Address - Phone:541-552-6692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OREGON UNIVERSITY SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORFP0000014261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical