Basic Information
Provider Information
NPI: 1891042487
EntityType: 2
ReplacementNPI:  
OrganizationName: CLACKAMAS COUNTY
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SUNNYSIDE HEALTH CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2051 KAEN RD STE 367
Address2:  
City: OREGON CITY
State: OR
PostalCode: 970454035
CountryCode: US
TelephoneNumber: 5037425300
FaxNumber: 5036558350
Practice Location
Address1: 9775 SE SUNNYSIDE RD STE 200
Address2:  
City: CLACKAMAS
State: OR
PostalCode: 970155721
CountryCode: US
TelephoneNumber: 5037943830
FaxNumber: 5037943850
Other Information
ProviderEnumerationDate: 08/14/2012
LastUpdateDate: 09/24/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: JOHNSON
AuthorizedOfficialFirstName: ED
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CFO
AuthorizedOfficialTelephone: 5037425325
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
03179905OR MEDICAID
50065339305OR MEDICAID
13160705OR MEDICAID
02271005OR MEDICAID


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