Provider Demographics
NPI:1952630576
Name:PEDIATRIC SPECIALISTS OF PENDLETON, LLC
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALISTS OF PENDLETON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PLATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-276-0250
Mailing Address - Street 1:2461 SW PERKINS AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-4301
Mailing Address - Country:US
Mailing Address - Phone:514-276-0250
Mailing Address - Fax:541-276-0253
Practice Address - Street 1:2461 SW PERKINS AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4301
Practice Address - Country:US
Practice Address - Phone:514-276-0250
Practice Address - Fax:541-276-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612592Medicaid