Provider Demographics
NPI:1659661346
Name:CENTRAL CITY CONCERN, INC.
Entity Type:Organization
Organization Name:CENTRAL CITY CONCERN, INC.
Other - Org Name:OLD TOWN CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-294-1681
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:503-294-4321
Practice Address - Street 1:727 W BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3514
Practice Address - Country:US
Practice Address - Phone:503-228-4533
Practice Address - Fax:503-228-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR381811Medicare Oscar/Certification