Healthcare Provider Details

I. General information

NPI: 1992725477
Provider Name (Legal Business Name): LEGACY MOUNT HOOD MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

PO BOX 4037
PORTLAND OR
97208-4037
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1230
  • Fax:
Mailing address:
  • Phone: 503-413-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberIP-000221-CS
License Number StateOR

VIII. Authorized Official

Name: LINDA S HOFF
Title or Position: SR VP AND CFO
Credential:
Phone: 503-415-5730