1669848792 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 1669848792 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:
Provider Other Organization Name Type Code:
6
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:
1669848792
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:
730 BIDDLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-494-3800
Provider Business Practice Location Address Fax Number:
541-494-0895
Provider Enumeration Date:
08/12/2015

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: 261QF0400X . This is a "CLINIC/CENTER/FEDERALLY QUALIFIED HEALTH CENTER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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