Provider Demographics
NPI:1811500671
Name:PRIDE NEUROSCIENCE GROUP LLC
Entity type:Organization
Organization Name:PRIDE NEUROSCIENCE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHONTHICHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-881-9459
Mailing Address - Street 1:2480 LIBERTY ST NE STE 180
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8388
Mailing Address - Country:US
Mailing Address - Phone:503-881-9459
Mailing Address - Fax:
Practice Address - Street 1:2480 LIBERTY ST NE STE 180
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8388
Practice Address - Country:US
Practice Address - Phone:503-881-9459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty