Provider Demographics
NPI:1154443646
Name:TILLAMOOK SPECIALIST ASSOCIATES, LLC
Entity Type:Organization
Organization Name:TILLAMOOK SPECIALIST ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SID
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-842-5546
Mailing Address - Street 1:980 3RD ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9469
Mailing Address - Country:US
Mailing Address - Phone:503-842-5546
Mailing Address - Fax:503-842-1444
Practice Address - Street 1:980 3RD ST
Practice Address - Street 2:SUITE 500
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9469
Practice Address - Country:US
Practice Address - Phone:503-842-5546
Practice Address - Fax:503-842-1444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TILLAMOOK MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213035Medicaid
OR213035Medicaid