Provider Demographics
NPI:1053545590
Name:CHILOQUIN FAMILY PRACTICE INC PC
Entity type:Organization
Organization Name:CHILOQUIN FAMILY PRACTICE INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-783-3412
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:CHILOQUIN
Mailing Address - State:OR
Mailing Address - Zip Code:97624-0331
Mailing Address - Country:US
Mailing Address - Phone:541-783-3412
Mailing Address - Fax:541-783-3412
Practice Address - Street 1:2825 RANCH RD
Practice Address - Street 2:
Practice Address - City:CHILOQUIN
Practice Address - State:OR
Practice Address - Zip Code:97624-5749
Practice Address - Country:US
Practice Address - Phone:541-783-3412
Practice Address - Fax:541-783-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287928Medicaid
ORR106823Medicare PIN