1780865642 NPI number — NORTHWEST RENAL CLINIC, INC.

Table of content: (NPI 1780865642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780865642 NPI number — NORTHWEST RENAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST RENAL CLINIC, 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:
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:
1780865642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 NW 22ND AVENUE
Provider Second Line Business Mailing Address:
SUITE 640
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-229-7976
Provider Business Mailing Address Fax Number:
503-274-4867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9155 SW BARNES RD STE 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-6631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-292-7704
Provider Business Practice Location Address Fax Number:
503-292-7046
Provider Enumeration Date:
11/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMILEY
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
503-229-7976

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119297 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".