Provider Demographics
NPI:1720017809
Name:CLACKAMAS COUNTY
Entity Type:Organization
Organization Name:CLACKAMAS COUNTY
Other - Org Name:BEAVERCREEK HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-742-5325
Mailing Address - Street 1:2051 KAEN RD
Mailing Address - Street 2:SUITE 367
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-655-8350
Practice Address - Street 1:110 BEAVERCREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4307
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-655-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022710Medicaid
OR022710Medicaid
OR381870Medicare Oscar/Certification
OR381820Medicare Oscar/Certification
OR381923Medicare Oscar/Certification
ORR134087Medicare PIN
OR381922Medicare Oscar/Certification
OR381936Medicare Oscar/Certification