Provider Demographics
NPI:1508832411
Name:FAMILY CARE CENTER PC
Entity Type:Organization
Organization Name:FAMILY CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-548-8088
Mailing Address - Street 1:1001 NW CANAL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1697
Mailing Address - Country:US
Mailing Address - Phone:541-548-8088
Mailing Address - Fax:541-548-8018
Practice Address - Street 1:1001 NW CANAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1697
Practice Address - Country:US
Practice Address - Phone:541-548-8088
Practice Address - Fax:541-548-8018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228793Medicaid
OR1194975037OtherINDIVIDUAL NPI
G78971Medicare UPIN
OR228793Medicaid
ORR113349Medicare PIN