Provider Demographics
NPI:1083915508
Name:CANBY HEALTHCARE CLINIC LLC
Entity Type:Organization
Organization Name:CANBY HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF ADULT NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:503-266-7686
Mailing Address - Street 1:18320 S WALKER RD
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-9326
Mailing Address - Country:US
Mailing Address - Phone:503-631-3420
Mailing Address - Fax:
Practice Address - Street 1:703 SE 1ST AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3849
Practice Address - Country:US
Practice Address - Phone:503-266-7686
Practice Address - Fax:503-266-7382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR085074804261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR152669Medicare UPIN