Provider Demographics
NPI:1164637641
Name:CLATSKANIE FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:CLATSKANIE FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-728-0424
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:401 SW BEL AIR
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-0927
Mailing Address - Country:US
Mailing Address - Phone:503-728-0424
Mailing Address - Fax:503-728-1297
Practice Address - Street 1:401 SW BEL AIR
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016-0927
Practice Address - Country:US
Practice Address - Phone:503-728-0424
Practice Address - Fax:503-728-1297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0713225100000X
OR000038358N2363LP0200X
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277982Medicaid
OR131558Medicare PIN