Provider Demographics
NPI:1427603968
Name:COUNTY OF TILLAMOOK
Entity Type:Organization
Organization Name:COUNTY OF TILLAMOOK
Other - Org Name:TILLAMOOK COUNTY HEALTH DEPARTMENT - MOBILE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-842-3922
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0489
Mailing Address - Country:US
Mailing Address - Phone:503-842-3900
Mailing Address - Fax:503-842-3903
Practice Address - Street 1:1925 SUPPRESS RD N
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9296
Practice Address - Country:US
Practice Address - Phone:503-842-3900
Practice Address - Fax:503-842-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128756Medicaid