Provider Demographics
NPI:1942415450
Name:BROOKINGS HARBOR FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:BROOKINGS HARBOR FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O.
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-469-2330
Mailing Address - Street 1:PO BOX 7529
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0344
Mailing Address - Country:US
Mailing Address - Phone:541-469-2330
Mailing Address - Fax:
Practice Address - Street 1:97825 SHOPPING CENTER AVE.
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19106208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR113115Medicare PIN
ORE08852Medicare UPIN