Basic Information
| Provider Information | |||||||||
| NPI: | 1033204334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOS COUNTY SCHOOL DISTRICT #13 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTH BEND SCHOOL DISTRICT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1913 MEADE STREET | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417562521 | ||||||||
| FaxNumber: | 5417561313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1913 MEADE STREET | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417562521 | ||||||||
| FaxNumber: | 5417561313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLENSTEINER | ||||||||
| AuthorizedOfficialFirstName: | BJ | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERINTENDENT | ||||||||
| AuthorizedOfficialTelephone: | 5417568304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 119466 | 05 | OR | MEDICAID |