| Llc | |
|
475 Elmira Ave Se Suite 103 Bandon OR 97411-7405 | |
| (541) 347-2111 | |
| (541) 347-1212 |
| Full Name | Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 475 Elmira Ave Se, Bandon, Oregon |
| Authorized Official Name and Position | Gail Koch Mcclave (OWNER) |
| Authorized Official Contact | 5413472111 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Llc Po Box 393 Bandon OR 97411 Ph: (541) 347-2111 | Llc 475 Elmira Ave Se Suite 103 Bandon OR 97411-7405 Ph: (541) 347-2111 |
| NPI Number | 1740368901 |
|---|---|
| Provider Enumeration Date | 11/02/2006 |
| Last Update Date | 05/16/2014 |
| Medicare PECOS PAC ID | 4587682133 |
|---|---|
| Medicare Enrollment ID | O20051102001011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740368901 | NPI | - | NPPES |
| 287386 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 207R00000X | Internal Medicine | (* (Not Available)) | Secondary |
| Provider Name | Gail K Mcclave |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1902964125 PECOS PAC ID: 8123077393 Enrollment ID: I20050113001097 |
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