Provider Demographics
NPI:1710307715
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PROVIDENCE HEALTH EXPRESS AT GATEWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-893-6524
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:SUITE 110A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9436
Practice Address - Country:US
Practice Address - Phone:855-229-6460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center