Provider Demographics
NPI:1275778235
Name:COLUMBIA REGIONAL PROGRAM-AUDIOLOGY
Entity Type:Organization
Organization Name:COLUMBIA REGIONAL PROGRAM-AUDIOLOGY
Other - Org Name:PORTLAND PUBLIC SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-916-5570
Mailing Address - Street 1:833 NE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6232
Mailing Address - Country:US
Mailing Address - Phone:503-916-5570
Mailing Address - Fax:503-916-2750
Practice Address - Street 1:833 NE 74TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-6232
Practice Address - Country:US
Practice Address - Phone:503-916-5570
Practice Address - Fax:503-916-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130293Medicaid