Provider Demographics
NPI:1528608288
Name:ELECTROLYSIS AND ESTHETIC BY JOANNE
Entity type:Organization
Organization Name:ELECTROLYSIS AND ESTHETIC BY JOANNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:LE
Authorized Official - Phone:541-670-8401
Mailing Address - Street 1:1183 NW RIVERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6168
Mailing Address - Country:US
Mailing Address - Phone:541-670-8401
Mailing Address - Fax:
Practice Address - Street 1:723 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3938
Practice Address - Country:US
Practice Address - Phone:541-670-8401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty