Provider Demographics
NPI:1114651171
Name:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
Entity Type:Organization
Organization Name:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF QUALITY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-512-3912
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:
Practice Address - Street 1:600 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2704
Practice Address - Country:US
Practice Address - Phone:541-535-6239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)