Provider Demographics
NPI:1730695032
Name:HALE2 MEN'S CLINIC, LLC
Entity type:Organization
Organization Name:HALE2 MEN'S CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIAN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:FERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-228-3660
Mailing Address - Street 1:1410 OAK ST STE 101
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4668
Mailing Address - Country:US
Mailing Address - Phone:541-228-3660
Mailing Address - Fax:541-228-3266
Practice Address - Street 1:1410 OAK ST STE 101
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4668
Practice Address - Country:US
Practice Address - Phone:541-228-3660
Practice Address - Fax:541-228-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNP201401588363L00000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR621399OtherNAICS CODE
9978OtherEFTPS