1174785869 NPI number — BEAR CREEK NATUROPATHICH CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174785869 NPI number — BEAR CREEK NATUROPATHICH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR CREEK NATUROPATHICH CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174785869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 E JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-7027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-770-5563
Provider Business Mailing Address Fax Number:
541-772-3028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 E JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-7027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-770-5563
Provider Business Practice Location Address Fax Number:
541-772-3028
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TICHAUER
Authorized Official First Name:
CORY
Authorized Official Middle Name:
SEAN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
541-770-5563

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X , with the licence number:  1324 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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