Provider Demographics
NPI:1124110325
Name:ROSEBURG VA HEALTH CARE SYSTEM
Entity type:Organization
Organization Name:ROSEBURG VA HEALTH CARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSELLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-440-1000
Mailing Address - Street 1:913 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6523
Mailing Address - Country:US
Mailing Address - Phone:541-957-0653
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6523
Practice Address - Country:US
Practice Address - Phone:541-957-0653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7677286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital