MEDICARE: TRANSITIONAL LIFE CARE CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1053839217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSITIONAL LIFE CARE CLINIC, INC.

Provider Business Mailing Address
First Line	:	15600 SW ROCK OF AGES RD
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8531
Country	:	US
Telephone Number	:	971-261-6130
Fax Number	:	971-261-6146

Provider Business Practice Location Address
First Line	:	15604 SW ROCK OF AGES RD
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8531
Country	:	US
Telephone Number	:	971-261-6130
Fax Number	:	971-241-6146

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DELVIN ZOOK
Credential	:	CEO
Telephone Number	:	503-550-4750

Provider Enumeration Date	:	09/07/2017
Last Update Date	:	11/21/2019

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