Healthcare Provider Details

I. General information

NPI: 1114253713
Provider Name (Legal Business Name): CANBY HEALTHCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 SE 1ST AVE
CANBY OR
97013-3849
US

IV. Provider business mailing address

703 SE 1ST AVE
CANBY OR
97013-3849
US

V. Phone/Fax

Practice location:
  • Phone: 503-266-7686
  • Fax: 503-266-7382
Mailing address:
  • Phone: 503-266-7686
  • Fax: 503-266-7382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAULINE L RICHARDS
Title or Position: OWNER
Credential: MANAGER
Phone: 503-266-7686