Basic Information
| Provider Information | |||||||||
| NPI: | 1740929355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELMORE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | RODNEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 627 NE 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97128 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 627 NE 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034347523 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2022 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.