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12750 Se Stark St Bldg E Portland OR 97233-1539 | |
| (971) 347-3009 | |
| (971) 256-3277 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 12750 Se Stark St Bldg E, Portland, Oregon |
| Authorized Official Name and Position | Sarah Ayers (CREDENTIALING SPECIALIST) |
| Authorized Official Contact | 5033679089 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
211 Se Caruthers St Portland OR 97214-4502 Ph: (503) 224-1044 | 12750 Se Stark St Bldg E Portland OR 97233-1539 Ph: (971) 347-3009 |
| NPI Number | 1174979934 |
|---|---|
| Provider Enumeration Date | 05/11/2016 |
| Last Update Date | 12/31/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1174979934 | NPI | - | NPPES |
| 126370 | Medicaid | OR | |
| 2273799 | Medicaid | WA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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