Basic Information
Provider Information | |||||||||
NPI: | 1508904681 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MULTNOMAH COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MULTNOMAH COUNTY HEALTH DEPT, LACLINICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 619 NW 6TH AVE STE 500 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972093964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039887468 | ||||||||
FaxNumber: | 5039883015 | ||||||||
Practice Location | |||||||||
Address1: | 6736 NE KILLINGSWORTH ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972183338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039887462 | ||||||||
FaxNumber: | 5039883015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 02/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEAR | ||||||||
AuthorizedOfficialFirstName: | WENDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS SERVICES MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5039887462 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0905X |   | OR | N |   | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | 261QF0400X |   | OR | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 022959 | 05 | OR |   | MEDICAID | 096511 | 05 | OR |   | MEDICAID |