MEDICARE: WATERFALL CLINIC INCORPORATED

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 State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619915113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERFALL CLINIC INCORPORATED

Provider Business Mailing Address
First Line	:	1890 WAITE ST
Second Line	:	SUITE 1
City	:	NORTH BEND
State	:	OR
Zip	:	97459-1229
Country	:	US
Telephone Number	:	541-756-6232
Fax Number	:	541-756-6234

Provider Business Practice Location Address
First Line	:	1890 WAITE ST
Second Line	:	SUITE 1
City	:	NORTH BEND
State	:	OR
Zip	:	97459-1229
Country	:	US
Telephone Number	:	541-756-6232
Fax Number	:	541-756-6234

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/CEO
Name	:	MRS. ANDREA TRENNER
Credential	:
Telephone Number	:	541-756-6232

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	06/30/2017

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Directions to “WATERFALL CLINIC INCORPORATED ” Practice Location

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