Provider Demographics
NPI:1174871552
Name:OREGON TLC
Entity type:Organization
Organization Name:OREGON TLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, ND
Authorized Official - Phone:541-255-1213
Mailing Address - Street 1:132 E BROADWAY
Mailing Address - Street 2:SUITE 716
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3143
Mailing Address - Country:US
Mailing Address - Phone:541-255-1213
Mailing Address - Fax:
Practice Address - Street 1:132 E BROADWAY
Practice Address - Street 2:SUITE 716
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3143
Practice Address - Country:US
Practice Address - Phone:541-255-1213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR221322081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty