Healthcare Provider Details

I. General information

NPI: 1528151362
Provider Name (Legal Business Name): COUNTY OF TILLAMOOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PACIFIC AVE
TILLAMOOK OR
97141-3926
US

IV. Provider business mailing address

801 PACIFIC AVE
TILLAMOOK OR
97141-3926
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD9427
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberMD11776
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARLENE L PUTMAN
Title or Position: ADMINISTRATOR
Credential: JD
Phone: 503-842-3900