Provider Demographics
NPI:1275880866
Name:CLACKAMAS COUNTY
Entity Type:Organization
Organization Name:CLACKAMAS COUNTY
Other - Org Name:GLADSTONE HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-742-5325
Mailing Address - Street 1:2051 KAEN RD STE 367
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-655-8350
Practice Address - Street 1:18911 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1630
Practice Address - Country:US
Practice Address - Phone:503-850-4472
Practice Address - Fax:503-850-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR031799Medicaid
OR131607Medicaid
OR022710Medicaid
ORR0000WCGMWMedicare PIN
OR022710Medicaid
OR031799Medicaid
OR131607Medicaid