Basic Information
| Provider Information | |||||||||
| NPI: | 1730695032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALE2 MEN'S CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HALE MEN'S CLINIC, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 OAK ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974014668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412283660 | ||||||||
| FaxNumber: | 5412283266 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 OAK ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974014668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412283660 | ||||||||
| FaxNumber: | 5412283266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2017 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERRY | ||||||||
| AuthorizedOfficialFirstName: | KRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5412283660 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP201401588 | OR | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 621399 | 01 | OR | NAICS CODE | OTHER | 9978 | 01 | EFTPS | OTHER |