Provider Demographics
NPI:1912462144
Name:EARTH SONG MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:EARTH SONG MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:PRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-BC
Authorized Official - Phone:541-237-4470
Mailing Address - Street 1:4567 DEER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:OR
Mailing Address - Zip Code:97538-9612
Mailing Address - Country:US
Mailing Address - Phone:541-237-4470
Mailing Address - Fax:
Practice Address - Street 1:18173 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:OR
Practice Address - Zip Code:97538
Practice Address - Country:US
Practice Address - Phone:541-237-4470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care