Organization
CLUB NORTHWEST
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STACY RAE CAPPADONA MS, RD, LD, CSCS (REGISTERED DIETITIAN)
(541) 955-2582
Entity
Organization
Contact information
Practice address
2160 NW VINE ST, GRANTS PASS, OR 97526-8439
(541) 955-2582
Mailing address
2160 NW VINE ST, GRANTS PASS, OR 97526-8439
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
Other
Enumeration date
11/07/2017
Last updated
11/07/2017
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