Provider Demographics
NPI:1104907609
Name:SOUTHERN OREGON NUTRITION & DIABETES TRAINING CENTER
Entity type:Organization
Organization Name:SOUTHERN OREGON NUTRITION & DIABETES TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPIVA
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:541-245-0713
Mailing Address - Street 1:825 E MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7133
Mailing Address - Country:US
Mailing Address - Phone:541-245-0713
Mailing Address - Fax:541-779-3526
Practice Address - Street 1:825 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7133
Practice Address - Country:US
Practice Address - Phone:541-245-0713
Practice Address - Fax:541-779-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115253Medicare ID - Type Unspecified