MEDICARE: OREGON FAMILY SUPPORT NETWORK

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1053971051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON FAMILY SUPPORT NETWORK

Provider Business Mailing Address
First Line	:	7110 SW FIR LOOP
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8084
Country	:	US
Telephone Number	:	971-209-5811
Fax Number	:

Provider Business Practice Location Address
First Line	:	7110 SW FIR LOOP
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8084
Country	:	US
Telephone Number	:	971-209-5811
Fax Number	:

Authorized Official
Title or Position	:	TRI-COUNTY REGIONL MANAGER
Name	:	SHANNON BOYETTE
Credential	:
Telephone Number	:	971-209-9292

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	06/20/2019

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Directions to “OREGON FAMILY SUPPORT NETWORK ” Practice Location

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