Basic Information
| Provider Information | |||||||||
| NPI: | 1922582493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OASIS CENTER OF THE ROGUE VALLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 E MAIN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412001530 | ||||||||
| FaxNumber: | 5417720284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 E MAIN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412001530 | ||||||||
| FaxNumber: | 5417720284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | HECOX | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5416217975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500196061 | 05 | OR | MEDICAID |