Basic Information
| Provider Information | |||||||||
| NPI: | 1811384423 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES-OREGON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ELDER AT HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
| FaxNumber: | 5032156644 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 NE GLISAN ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032150750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | METCALF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5032155491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OR | N | Agencies | Case Management | 261Q00000X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.