Provider Demographics
NPI:1407854243
Name:PRIMARY CARE WEST, P.C.
Entity Type:Organization
Organization Name:PRIMARY CARE WEST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LEANNE
Authorized Official - Last Name:HOVENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-362-1314
Mailing Address - Street 1:1255 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3007
Mailing Address - Country:US
Mailing Address - Phone:503-362-1314
Mailing Address - Fax:
Practice Address - Street 1:1255 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-362-1314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13749261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278804Medicaid
OR021159Medicaid
OR019179Medicaid
ORS92572Medicare UPIN
ORR0000WCLBGAMedicare PIN
ORD26347Medicare UPIN
ORD28627Medicare UPIN