Basic Information
| Provider Information | |||||||||
| NPI: | 1194756114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAPHNE MED LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SELF INTEGRATIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1208 BEALL LN | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975021573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416645151 | ||||||||
| FaxNumber: | 5416645155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 SISKIYOU BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416645151 | ||||||||
| FaxNumber: | 5416645155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SELF | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5416645151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.