Healthcare Provider Details

I. General information

NPI: 1558806406
Provider Name (Legal Business Name): CHILDRENS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2017
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 DEBORAH RD STE 150
NEWBERG OR
97132-2198
US

IV. Provider business mailing address

700 DEBORAH RD STE 150
NEWBERG OR
97132-2198
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-6791
  • Fax: 503-554-0549
Mailing address:
  • Phone: 503-538-6791
  • Fax: 503-554-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KELSEY DURHAM
Title or Position: HEALTH PLAN COORDINATOR
Credential:
Phone: 503-535-6314