1720105489 NPI number — LUTHERAN COMMUNITY SERVICES NORTHWEST

Table of content: (NPI 1720105489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720105489 NPI number — LUTHERAN COMMUNITY SERVICES NORTHWEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTHERAN COMMUNITY SERVICES NORTHWEST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720105489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2545 N ELDORADO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97601-6423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-883-3471
Provider Business Mailing Address Fax Number:
541-883-3524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2545 N ELDORADO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97601-6423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-883-3471
Provider Business Practice Location Address Fax Number:
541-883-3524
Provider Enumeration Date:
03/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
SHELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
541-201-3973

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 090450 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 026825000 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".