Healthcare Provider Details

I. General information

NPI: 1841483252
Provider Name (Legal Business Name): CHILDREN'S COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 LLOYD CTR
PORTLAND OR
97232-1311
US

IV. Provider business mailing address

2250 LLOYD CTR
PORTLAND OR
97232-1311
US

V. Phone/Fax

Practice location:
  • Phone: 503-284-5239
  • Fax: 503-284-9162
Mailing address:
  • Phone: 503-284-5239
  • Fax: 503-284-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARDICA HICKS
Title or Position: CEO
Credential:
Phone: 503-284-5239