Healthcare Provider Details

I. General information

NPI: 1619588175
Provider Name (Legal Business Name): HOLY FAMILY CATHOLIC CLINIC, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21810 WILLAMETTE DR
WEST LINN OR
97068-3256
US

IV. Provider business mailing address

21810 WILLAMETTE DR
WEST LINN OR
97068-3256
US

V. Phone/Fax

Practice location:
  • Phone: 503-994-4353
  • Fax:
Mailing address:
  • Phone: 503-994-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA JOSE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 503-994-4353