Healthcare Provider Details

I. General information

NPI: 1104097906
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 11TH AVE
LONGVIEW WA
98632-2503
US

IV. Provider business mailing address

PO BOX 31001 - 4180
PASADENA CA
91110-4180
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-1771
  • Fax:
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
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