1083120471 NPI number — QUEST CENTER CLACKAMAS

Table of content: (NPI 1083120471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083120471 NPI number — QUEST CENTER CLACKAMAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEST CENTER CLACKAMAS
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:
QUEST CENTER FOR INTEGRATIVE HEALTH
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:
1083120471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 E BURNSIDE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97214-1831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-238-5203
Provider Business Mailing Address Fax Number:
503-445-0120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 BEAVERCREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-238-5203
Provider Business Practice Location Address Fax Number:
503-238-5202
Provider Enumeration Date:
12/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BRANDT
Authorized Official First Name:
JANET
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIRECTOR OF FINANCE AND ADMIN
Authorized Official Telephone Number:
503-238-5203

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 287030 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500661304 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500665091 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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