| Centennial School Base | |
|
3505 Se 182nd Ave Gresham OR 97030-5028 | |
| (503) 988-5488 | |
| (503) 988-5484 |
| Full Name | Centennial School Base |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 3505 Se 182nd Ave, Gresham, Oregon |
| Authorized Official Name and Position | Derrick Moten (INTERIM BUSINESS SERVICES DIRECTOR) |
| Authorized Official Contact | 5039882966 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Centennial School Base 619 Nw 6th Ave Ste 500 Portland OR 97209-3964 Ph: (503) 988-7468 | Centennial School Base 3505 Se 182nd Ave Gresham OR 97030-5028 Ph: (503) 988-5488 |
| NPI Number | 1912322074 |
|---|---|
| Provider Enumeration Date | 02/26/2014 |
| Last Update Date | 05/18/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912322074 | NPI | - | NPPES |
| 096511 | Medicaid | OR | |
| 22959 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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