Provider Demographics
NPI:1043740616
Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Other - Org Name:ADVENTIST HEALTH TILLAMOOK MEDICAL GROUP - BANKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FO
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-815-2263
Mailing Address - Street 1:PO BOX 888860
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12350 NW MAIN ST STE 112
Practice Address - Street 2:
Practice Address - City:BANKS
Practice Address - State:OR
Practice Address - Zip Code:97106-9045
Practice Address - Country:US
Practice Address - Phone:503-842-4444
Practice Address - Fax:503-815-2330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-15
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
OR141177282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access