Provider Demographics
NPI:1699207324
Name:FOREST GROVE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:FOREST GROVE HEALTHCARE, LLC
Other - Org Name:MELINDA A. SANFILIPPO
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO & PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SANFILIPPO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:503-433-7757
Mailing Address - Street 1:4363 SW ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-8530
Mailing Address - Country:US
Mailing Address - Phone:503-433-7757
Mailing Address - Fax:503-433-7762
Practice Address - Street 1:356 SE 9TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4202
Practice Address - Country:US
Practice Address - Phone:503-433-7757
Practice Address - Fax:503-433-7762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201708826NP261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
R179267Medicare Oscar/Certification
R179267Medicare PIN
R179267Medicare UPIN