Provider Demographics
NPI:1114469103
Name:SAMARITAN HEALTH SERVICES
Entity Type:Organization
Organization Name:SAMARITAN HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:541-232-9615
Mailing Address - Street 1:117 SW 4TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4717
Mailing Address - Country:US
Mailing Address - Phone:541-232-9615
Mailing Address - Fax:
Practice Address - Street 1:620 ELM ST SW # 2
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1986
Practice Address - Country:US
Practice Address - Phone:541-812-4839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
86065504OtherCOMMISION ON DIETETIC REGISTRATION
ORLDD10175002OtherOREGON DIETETIC LICENSURE