Provider Demographics
NPI:1811384423
Name:PROVIDENCE HEALTH & SERVICES-OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-OREGON
Other - Org Name:PROVIDENCE ELDER AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-215-5491
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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4900 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2936
Practice Address - Country:US
Practice Address - Phone:503-215-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251B00000X, 261Q00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center