1720023807 NPI number — DEPT. OF HUMAN SRVCS/OFFICE OF FIN. SRVCS DBA: IRS/EOPC/EOTC/OSH/OSH-P

Table of content: (NPI 1720023807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720023807 NPI number — DEPT. OF HUMAN SRVCS/OFFICE OF FIN. SRVCS DBA: IRS/EOPC/EOTC/OSH/OSH-P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPT. OF HUMAN SRVCS/OFFICE OF FIN. SRVCS DBA: IRS/EOPC/EOTC/OSH/OSH-P
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:
1720023807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97309-5016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-945-9469
Provider Business Mailing Address Fax Number:
503-947-1007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 WESTGATE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801-9613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-276-0820
Provider Business Practice Location Address Fax Number:
541-276-1147
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KITTRELL
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
INSTITUTIONAL REVENUE SECTION MGR.
Authorized Official Telephone Number:
503-945-9440

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  6021 , 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: 400093 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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