=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972039170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES OREGON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2017
-----------------------------------------------------
Last Update Date | 05/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 S HIGHWAY 101
-----------------------------------------------------
City | WARRENTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97146-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-861-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001-4199
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-893-7120
-----------------------------------------------------
Fax | 425-276-3215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY ENROLLMENTS
-----------------------------------------------------
Name | DONALD W ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------