Provider Demographics
NPI:1194756114
Name:DAPHNE MED LLC
Entity type:Organization
Organization Name:DAPHNE MED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-664-5151
Mailing Address - Street 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:541-664-5155
Practice Address - Street 1:1630 SISKIYOU BLVD STE B
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2423
Practice Address - Country:US
Practice Address - Phone:541-664-5151
Practice Address - Fax:541-664-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR135415Medicare PIN