Healthcare Provider Details

I. General information

NPI: 1013254432
Provider Name (Legal Business Name): PENDLETON PRIMARY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 11
PENDLETON OR
97801-3973
US

IV. Provider business mailing address

1100 SOUTHGATE STE 11
PENDLETON OR
97801-3973
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-6916
  • Fax: 541-215-1405
Mailing address:
  • Phone: 541-966-6916
  • Fax: 541-215-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMI J FOSTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-966-6916