Basic Information
| Provider Information | |||||||||
| NPI: | 1376925719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ENDOCRINOLOGY ASSOCIATES, LLC | ||||||||
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| OtherOrganizationName: | PREMIER ENDOCRINOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 BELLEVUE ST SE | ||||||||
| Address2: | SUITE #290 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039674240 | ||||||||
| FaxNumber: | 5033399546 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 LIBERTY STREET SE SUITE 170 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039674240 | ||||||||
| FaxNumber: | 5033399546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LOARCA | ||||||||
| AuthorizedOfficialFirstName: | LETICIA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5039674240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER ENDOCRINOLOGY ASSOCIATES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD-D-000451 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 163WD0400X | LD-D-000451 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 26956 | 05 | OR | MEDICAID |