Healthcare Provider Details

I. General information

NPI: 1467934661
Provider Name (Legal Business Name): COLUMBIA RIVER HEALTH-PENDLETON HIGH SCHOOL SBHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NW CARDEN AVE
PENDLETON OR
97801-1185
US

IV. Provider business mailing address

PO BOX 397
BOARDMAN OR
97818-0397
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-3857
  • Fax:
Mailing address:
  • Phone: 541-481-7212
  • Fax: 541-481-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANJUANITA CANTU
Title or Position: BILLING/CREDENTIALING SERVICES MGR
Credential:
Phone: 541-481-7212