| |
1631 Sw Columbia St Portland OR 97201-6025 | |
(503) 231-2641 | |
(503) 231-1654 |
Full Name | |
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Speciality | Clinic/Center |
Location | 1631 Sw Columbia St, Portland, Oregon |
Authorized Official Name and Position | Sarah Ayers (CREDENTIALING SPECIALIST) |
Authorized Official Contact | 5033679089 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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1776 Sw Madison St Portland OR 97205 Ph: (503) 224-1044 | 1631 Sw Columbia St Portland OR 97201-6025 Ph: (503) 231-2641 |
NPI Number | 1932190550 |
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Provider Enumeration Date | 11/02/2005 |
Last Update Date | 04/12/2024 |
Medicare PECOS PAC ID | 2668361585 |
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Medicare Enrollment ID | O20101020000104 |
Identifier | Type | State | Issuer |
---|---|---|---|
1932190550 | NPI | - | NPPES |
126370 | Medicaid | OR | |
2030217 | Medicaid | WA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Oregon) | Primary |
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