Provider Demographics
NPI:1639468432
Name:CASCADE WEST MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:CASCADE WEST MEDICAL PRACTICE LLC
Other - Org Name:CASCADE WEST PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-450-8345
Mailing Address - Street 1:PO BOX 738
Mailing Address - Street 2:
Mailing Address - City:MERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97532-0738
Mailing Address - Country:US
Mailing Address - Phone:541-787-4360
Mailing Address - Fax:360-216-7677
Practice Address - Street 1:201 NE SAVAGE ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1309
Practice Address - Country:US
Practice Address - Phone:541-787-4360
Practice Address - Fax:360-216-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850056NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28641Medicare UPIN