Healthcare Provider Details

I. General information

NPI: 1154741916
Provider Name (Legal Business Name): WOODBURN PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

IV. Provider business mailing address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

V. Phone/Fax

Practice location:
  • Phone: 503-981-5348
  • Fax: 503-467-5588
Mailing address:
  • Phone: 503-981-5348
  • Fax: 503-467-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DEBRA E BARTEL
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 503-981-5348