Provider Demographics
NPI:1033469663
Name:COLUMBIA LUTHERAN CHARITIES
Entity Type:Organization
Organization Name:COLUMBIA LUTHERAN CHARITIES
Other - Org Name:CMH PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-325-4321
Mailing Address - Street 1:2111 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3329
Mailing Address - Country:US
Mailing Address - Phone:503-338-4500
Mailing Address - Fax:503-338-4501
Practice Address - Street 1:1639 SE ENSIGN LN
Practice Address - Street 2:SUITE B103
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-7308
Practice Address - Country:US
Practice Address - Phone:503-338-4500
Practice Address - Fax:503-338-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR388515OtherMEDICARE PTAN
OR388515OtherMEDICARE PTAN