Provider Demographics
NPI:1578090221
Name:RCH HEP C PROGRAM
Entity Type:Organization
Organization Name:RCH HEP C PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-842-7642
Mailing Address - Street 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7136
Practice Address - Country:US
Practice Address - Phone:541-842-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROGUE COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-12
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667341Medicaid
OR227698Medicaid