Provider Demographics
NPI:1053957225
Name:RIVER ROCK FAMILY PRACTICE PC
Entity type:Organization
Organization Name:RIVER ROCK FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-226-9840
Mailing Address - Street 1:3144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-226-9840
Mailing Address - Fax:
Practice Address - Street 1:3144 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-226-9840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER ROCK FAMILY PRACTICE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR026845OtherDMAP
OR200550153NPOtherFNPC
OR1356355846OtherNPI INDIVIDUAL
OR1356355846OtherNPI INDIVIDUAL