{
"Npi": {
"NPI": "1972039170",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PROVIDENCE HEALTH & SERVICES OREGON",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 31001-4199",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PASADENA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91110-4199",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "503-893-7120",
"MailingAddressFaxNumber": "425-276-3215",
"FirstLinePracticeLocationAddress": "113 S HIGHWAY 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WARRENTON",
"PracticeLocationAddressStateName": "OR",
"PracticeLocationAddressPostalCode": "97146-9314",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "503-861-6500",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/08/2017",
"LastUpdateDate": "05/21/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ANDERSON",
"AuthorizedOfficialFirstName": "DONALD",
"AuthorizedOfficialMiddleName": "W",
"AuthorizedOfficialTitle": "ASSISTANT SECRETARY ENROLLMENTS",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "425-358-9786",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM1300X",
"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QR1300X",
"TaxonomyName": "Rural Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}