Provider Demographics
NPI:1639651839
Name:COLUMBIA RIVER HEALTH-SUNRIDGE MIDDLE SCHOOL SBHC
Entity Type:Organization
Organization Name:COLUMBIA RIVER HEALTH-SUNRIDGE MIDDLE SCHOOL SBHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING SERVICES MGR
Authorized Official - Prefix:
Authorized Official - First Name:SANJUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-481-7212
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818-0397
Mailing Address - Country:US
Mailing Address - Phone:541-481-7212
Mailing Address - Fax:541-481-5400
Practice Address - Street 1:700 SW RUNNION AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9418
Practice Address - Country:US
Practice Address - Phone:541-966-3432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA RIVER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276286Medicaid