Provider Demographics
NPI:1376917641
Name:BASIC FAMILY HEALTHCARE INC
Entity Type:Organization
Organization Name:BASIC FAMILY HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:MELODY
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-241-3071
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0059
Mailing Address - Country:US
Mailing Address - Phone:541-241-3071
Mailing Address - Fax:541-241-8031
Practice Address - Street 1:1813 W HARVARD AVE STE 233
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8704
Practice Address - Country:US
Practice Address - Phone:541-241-3071
Practice Address - Fax:541-241-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
IDNP-878A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1700049152OtherPROVIDER NPI
ID1700049152OtherPROVIDER NPI
ID377696Medicare UPIN