Provider Demographics
NPI:1306244694
Name:CHILDREN'S HEART CENTER OF CENTRAL OREGON LLC
Entity type:Organization
Organization Name:CHILDREN'S HEART CENTER OF CENTRAL OREGON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:URSZULA
Authorized Official - Middle Name:WANDA
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-385-3048
Mailing Address - Street 1:2041 NE WILLIAMSON CT. SUITE A
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-639-8333
Mailing Address - Fax:541-749-2126
Practice Address - Street 1:2041 NE WILLIAMSON CT STE A
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3941
Practice Address - Country:US
Practice Address - Phone:541-639-8333
Practice Address - Fax:541-749-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23398174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty