Provider Demographics
NPI:1568443018
Name:COLUMBIA RIVER WOMEN'S CLINIC, LLC
Entity Type:Organization
Organization Name:COLUMBIA RIVER WOMEN'S CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT, CCS-P
Authorized Official - Phone:541-296-5657
Mailing Address - Street 1:1810 E 19TH ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-5657
Mailing Address - Fax:
Practice Address - Street 1:1810 E 19TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-5657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227699Medicaid
OR227699Medicaid