Provider Demographics
NPI:1609065010
Name:UMPQUA COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:UMPQUA COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-672-9596
Mailing Address - Street 1:150 KENNETH FORD DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1042
Mailing Address - Country:US
Mailing Address - Phone:541-672-9596
Mailing Address - Fax:541-464-3519
Practice Address - Street 1:20170 NORTH UMPQUA HIGHWAY
Practice Address - Street 2:
Practice Address - City:GLIDE
Practice Address - State:OR
Practice Address - Zip Code:97443
Practice Address - Country:US
Practice Address - Phone:541-496-3504
Practice Address - Fax:541-464-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OR261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168395Medicaid
38-1846Medicare PIN
OR38-1846Medicare PIN