MEDICARE: BENTON COUNTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	03932800	OTHER	REGENCE BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	700228501	OTHER	REGENCE BCBS

General Provider Information

NPI Number	:	1093997710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENTON COUNTY

Provider Business Mailing Address
First Line	:	PO BOX 579
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97339-0579
Country	:	US
Telephone Number	:	541-766-6835
Fax Number	:	541-766-6186

Provider Business Practice Location Address
First Line	:	100 MULLINS DR STE A1
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-2868
Country	:	US
Telephone Number	:	541-766-0200
Fax Number	:	541-766-6618

Authorized Official
Title or Position	:	HEALTH CENTER DIRECTOR
Name	:	MRS. LACEY MOLLEL
Credential	:
Telephone Number	:	541-766-6835

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	05/01/2025

Similar Medicare Providers

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Practice Location Address:

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1306129614 — WANDA CAROL NEWSOME CNP
Practice Location Address:

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Directions to “BENTON COUNTY ” Practice Location

Language	Start Address	Practice Location

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