Basic Information
| Provider Information | |||||||||
| NPI: | 1922248327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULTNOMAH COUNTY | ||||||||
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| 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: | 5210 N KERBY AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972172656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883360 | ||||||||
| FaxNumber: | 5039885780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2009 | ||||||||
| LastUpdateDate: | 03/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEAR | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5039883663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF MULTNOMAH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | 022959 | 05 | OR | MEDICAID |