Provider Demographics
NPI:1417975152
Name:WOMEN'S HEALTH CENTER OF OREGON
Entity Type:Organization
Organization Name:WOMEN'S HEALTH CENTER OF OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-905-4361
Mailing Address - Street 1:1508 DIVISION ST
Mailing Address - Street 2:STE 205
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-657-1071
Mailing Address - Fax:503-657-3321
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCLBWMedicare PIN