Healthcare Provider Details

I. General information

NPI: 1710084140
Provider Name (Legal Business Name): COLUMBIA RIVER HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 TATONE STREET
BOARDMAN OR
97818
US

IV. Provider business mailing address

PO BOX 397
BOARDMAN OR
97818
US

V. Phone/Fax

Practice location:
  • Phone: 541-481-7212
  • Fax: 541-481-2020
Mailing address:
  • Phone: 541-481-7212
  • Fax: 541-481-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier276286
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: SANJUANITA OLIVAS
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 541-481-5448