Basic Information
| Provider Information | |||||||||
| NPI: | 1619367984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | FAVOURE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVENUE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
| FaxNumber: | 5419565463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 W 11TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4168626885 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2015 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.