Provider Demographics
NPI:1710910781
Name:COUNTY OF POLK
Entity Type:Organization
Organization Name:COUNTY OF POLK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-623-8173
Mailing Address - Street 1:182 SW ACADEMY STREET
Mailing Address - Street 2:SUITE 302
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1922
Mailing Address - Country:US
Mailing Address - Phone:503-623-8175
Mailing Address - Fax:503-831-3499
Practice Address - Street 1:182 SW ACADEMY STREET
Practice Address - Street 2:SUITE 302
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-623-8175
Practice Address - Fax:503-831-3499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043526Medicaid
OR096610Medicaid
OR320101Medicaid
OR096610Medicaid