Healthcare Provider Details

I. General information

NPI: 1235177288
Provider Name (Legal Business Name): OAK STREET HEALTH CARE CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 OAK ST
BROOKINGS OR
97415-9612
US

IV. Provider business mailing address

PO BOX 6579
BROOKINGS OR
97415-0285
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-8898
  • Fax: 541-412-7420
Mailing address:
  • Phone: 541-412-8898
  • Fax: 541-412-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEE M WILSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 541-469-6023