Healthcare Provider Details

I. General information

NPI: 1114469103
Provider Name (Legal Business Name): SAMARITAN HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ELM ST SW # 2
ALBANY OR
97321-1986
US

IV. Provider business mailing address

117 SW 4TH ST APT 2
CORVALLIS OR
97333-4717
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-4839
  • Fax:
Mailing address:
  • Phone: 541-232-9615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN DOUGLAS WYMORE
Title or Position: REGISTERED DIETITIAN
Credential: RD, LD
Phone: 541-232-9615