MEDICARE: GLENDALE COMMUNITY PRIMARY CARE

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1114480399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE COMMUNITY PRIMARY CARE

Provider Business Mailing Address
First Line	:	PO BOX 293
Second Line	:
City	:	GLENDALE
State	:	OR
Zip	:	97442-0293
Country	:	US
Telephone Number	:	541-832-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 1ST ST
Second Line	:
City	:	GLENDALE
State	:	OR
Zip	:	97442-9640
Country	:	US
Telephone Number	:	541-832-5400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEONA MARIE ANDERSON
Credential	:	DNP, AGPCNP-C
Telephone Number	:	541-832-5400

Provider Enumeration Date	:	04/13/2019
Last Update Date	:	08/10/2020

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Directions to “GLENDALE COMMUNITY PRIMARY CARE ” Practice Location

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