Basic Information
| Provider Information | |||||||||
| NPI: | 1699132308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODGE | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | RENEE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3397 DELTA WATERS RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417724648 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1025 E MAIN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412001530 | ||||||||
| FaxNumber: | 5417720284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.