Provider Demographics
NPI:1437816659
Name:PROVIDENCE HEALTH SYSTEMS
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN CM
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-513-1300
Mailing Address - Street 1:10330 SE 32ND AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6596
Mailing Address - Country:US
Mailing Address - Phone:503-717-3013
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6596
Practice Address - Country:US
Practice Address - Phone:503-717-3013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR931146501Medicaid