Provider Demographics
NPI:1376768572
Name:HEALING PRESENCE FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:HEALING PRESENCE FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:RAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:503-819-9726
Mailing Address - Street 1:29030 SW TOWN CENTER LOOP E
Mailing Address - Street 2:SUITE 202 PO BOX 260
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9490
Mailing Address - Country:US
Mailing Address - Phone:503-819-9726
Mailing Address - Fax:503-582-8337
Practice Address - Street 1:30250 SW PARKWAY AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9757
Practice Address - Country:US
Practice Address - Phone:503-819-9726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR070131Medicaid
ORP 84206Medicare UPIN