Healthcare Provider Details

I. General information

NPI: 1588999007
Provider Name (Legal Business Name): FOUR RIVERS HEALTHCARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 W IDAHO AVE STE 100
ONTARIO OR
97914-2155
US

IV. Provider business mailing address

640 SW 4TH AVE
ONTARIO OR
97914-2625
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2244
  • Fax: 541-889-2626
Mailing address:
  • Phone: 541-889-3510
  • Fax: 541-889-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200550081NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number07904
License Number StateOR

VIII. Authorized Official

Name: JODY AILEEN STARK
Title or Position: PRESIDENT
Credential: FNP
Phone: 541-889-2244