Provider Demographics
NPI:1376625137
Name:PROVIDENCE HEALTH & SERVICES-OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-OREGON
Other - Org Name:PROVIDENCE CHILD CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC ENROLLMT/DIR REIMB REG
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:830 NE 47TH AVE
Mailing Address - Street 2:ATTN: FINANCE
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2212
Mailing Address - Country:US
Mailing Address - Phone:503-215-2400
Mailing Address - Fax:503-215-0660
Practice Address - Street 1:830 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2212
Practice Address - Country:US
Practice Address - Phone:503-215-2400
Practice Address - Fax:503-215-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1700250565313M00000X
OR10354532593140N1450X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1035453259OtherDEPT OF HUMAN SVCS
OR807297Medicaid
WA4570701Medicaid