Provider Demographics
NPI:1699132308
Name:DODGE, RENEE L
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:L
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:L
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3397 DELTA WATERS RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5852
Mailing Address - Country:US
Mailing Address - Phone:541-772-4648
Mailing Address - Fax:
Practice Address - Street 1:1025 E MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7690
Practice Address - Country:US
Practice Address - Phone:541-200-1530
Practice Address - Fax:541-772-0284
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator