# CLUB NORTHWEST

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356854830
- **Authorized official:** STACY RAE CAPPADONA MS, RD, LD, CSCS (REGISTERED DIETITIAN)
- **Authorized official phone:** (541) 955-2582

## Contact information

- **Practice address:** 2160 NW VINE ST, GRANTS PASS, OR 97526-8439
- **Practice address phone:** (541) 955-2582
- **Mailing address:** 2160 NW VINE ST, GRANTS PASS, OR 97526-8439

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 11/07/2017
- **Last updated:** 11/07/2017