Basic Information
| Provider Information | |||||||||
| NPI: | 1417357443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULTNOMAH COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STD PIVOT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 SW 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034457699 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2014 | ||||||||
| LastUpdateDate: | 09/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEAR | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5039887511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0905X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
ID Information
| ID | Type | State | Issuer | Description | 22959 | 05 | OR | MEDICAID | 096511 | 05 | OR | MEDICAID |