Basic Information
| Provider Information | |||||||||
| NPI: | 1821757527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MULNOMAH COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 SW 6TH AVE. | ||||||||
| Address2: | 5TH FL | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1698 SW CHERRY PARK RD | ||||||||
| Address2: | |||||||||
| City: | TROUTDALE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970601481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | GADDIS | ||||||||
| AuthorizedOfficialFirstName: | CAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5039887468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 22959 | 05 | OR | MEDICAID |