1821333402 NPI number — LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.

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 1821333402 NPI number — LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
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:
LA CLINICA SCHOOL-BASED HEALTH CENTER AT PHOENIX ELEMENTARY SCHOOL
Provider Other Organization Name Type Code:
3
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:
1821333402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
931 CHEVY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-4127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-535-6239
Provider Business Mailing Address Fax Number:
541-842-2212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N ROSE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-535-1065
Provider Business Practice Location Address Fax Number:
541-512-2082
Provider Enumeration Date:
12/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JEANNOT
Authorized Official First Name:
TARA
Authorized Official Middle Name:
LYNETTE
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
541-535-6239

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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: 022868 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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