Provider Demographics
NPI:1508133299
Name:WATERFALL CLINIC, INCORPORATED
Entity Type:Organization
Organization Name:WATERFALL CLINIC, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO ASST.
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:MCFERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-435-7033
Mailing Address - Street 1:1890 WAITE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:826 S 11TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERFALL CLINIC, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-23
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647633Medicaid