North Lake Clinic, LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

MD07786 Issued in OR

Legal business name

NORTH LAKE CLINIC, LLC

Practice address

87520 Bay Rd
Christmas Valley, OR 97641-0377

Phone

(541) 576-2343

Fax

(541) 576-2869

NPI assigned

May 19, 2009

Last updated

May 19, 2009By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Bruce D Carlson, M.D.

Title

Owner

Phone

(541) 576-2343

Specialties & licenses 1

Addresses

Other identifiers 2

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Dennis M. Bruneau, PA-C

  • Physician Assistant
  • Christmas Valley, OR
  • NPI 1497810915
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1242691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1242691200000",
    "number": "1669607792",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 377",
            "city": "CHRISTMAS VALLEY",
            "state": "OR",
            "postal_code": "976410377",
            "telephone_number": "541-576-2343",
            "fax_number": "541-576-2869"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "87520 BAY RD",
            "city": "CHRISTMAS VALLEY",
            "state": "OR",
            "postal_code": "976410377",
            "telephone_number": "541-576-2343",
            "fax_number": "541-576-2869"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH LAKE CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-19",
        "last_updated": "2009-05-19",
        "status": "A",
        "authorized_official_last_name": "CARLSON",
        "authorized_official_first_name": "BRUCE",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "541-576-2343",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "OR",
            "license": "MD07786",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF OREGON",
            "identifier": "080385000",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "182817",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Larissa Briaun Hackett
• Shawn Kimberly Lavallee
• Emily Louise Merwin
• Kendra Murphy
• North Lake Clinic LLC (North Lake Clinic)
• North Lake County Emergency Medical Service, Inc.
• Pat Widenoja FNP (North Lake Clinic)
• Holly Vore, QMHP1

• Rural Health Clinic/Center in Christmas Valley, OR
• Providers in Christmas Valley, OR by specialty
• Rural Health Clinic/Center in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.