1821268822 NPI number — WILLAMETTE CLINIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821268822 NPI number — WILLAMETTE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLAMETTE CLINIC, LLC
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:
1821268822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1750 BLANKENSHIP ROAD
Provider Second Line Business Mailing Address:
SUITE 280
Provider Business Mailing Address City Name:
WEST LINN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97068-8269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-496-0290
Provider Business Mailing Address Fax Number:
503-496-3166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 BLANKENSHIP ROAD
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
WEST LINN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97068-8269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-496-0290
Provider Business Practice Location Address Fax Number:
503-496-3166
Provider Enumeration Date:
03/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LAIRD
Authorized Official First Name:
SHERI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-496-0290

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD21936 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 134282 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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