Basic Information
| Provider Information | |||||||||
| NPI: | 1083384747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULNOMAH COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 NW 6TH AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972093964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 NE 68TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972134957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2021 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | GADDIS | ||||||||
| AuthorizedOfficialFirstName: | CAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5039887468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MULTNOMAH COUNTY | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 022959 | 05 | OR | MEDICAID |