1972039170 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Table of content: (NPI 1972039170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972039170 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES OREGON
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:
1972039170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-4199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-4199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-893-7120
Provider Business Mailing Address Fax Number:
425-276-3215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 S HIGHWAY 101 STE 113
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97146-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-861-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ASSISTANT SECRETARY ENROLLMENTS
Authorized Official Telephone Number:
425-358-9786

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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