Provider Demographics
NPI:1962041707
Name:SHIFT BEND FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:SHIFT BEND FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEDICAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, DNP
Authorized Official - Phone:541-219-1910
Mailing Address - Street 1:556 NW TRENTON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1126
Mailing Address - Country:US
Mailing Address - Phone:541-219-1910
Mailing Address - Fax:
Practice Address - Street 1:151 SW SHEVLIN HICKS DR
Practice Address - Street 2:SUITE #1
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-219-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty