Provider Demographics
NPI:1114253713
Name:CANBY HEALTHCARE CLINIC LLC
Entity Type:Organization
Organization Name:CANBY HEALTHCARE CLINIC LLC
Other - Org Name:CANBY HEALTHCARE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:503-266-7686
Mailing Address - Street 1:703 SE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3849
Mailing Address - Country:US
Mailing Address - Phone:503-266-7686
Mailing Address - Fax:503-266-7382
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:2009-11-02
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500618933Medicaid
OR500618933Medicaid