Provider Demographics
NPI:1376520163
Name:O'DONOVAN CLINIC, INC.
Entity Type:Organization
Organization Name:O'DONOVAN CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-738-5571
Mailing Address - Street 1:580 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-5065
Mailing Address - Country:US
Mailing Address - Phone:503-738-5571
Mailing Address - Fax:503-738-5573
Practice Address - Street 1:580 AVENUE U
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-5065
Practice Address - Country:US
Practice Address - Phone:503-738-5571
Practice Address - Fax:503-738-5573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00038357261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286279Medicaid
ORR114259Medicare PIN
OR286279Medicaid