Healthcare Provider Details

I. General information

NPI: 1285201798
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8605 COMMERCE PLACE DR NE STE A
LACEY WA
98516-3813
US

IV. Provider business mailing address

PO BOX 5936A
PORTLAND OR
97228-5936
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-4333
  • Fax:
Mailing address:
  • Phone: 503-215-4663
  • Fax: 503-215-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786