Provider Demographics
NPI:1851327571
Name:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Entity Type:Organization
Organization Name:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Other - Org Name:PHOENIX HEALTH CENTER- LA CLINICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:JEANNOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-535-6239
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:541-842-2212
Practice Address - Street 1:3617 S PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-535-6239
Practice Address - Fax:541-512-1026
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 122300000X, 126800000X, 163W00000X, 207Q00000X, 207V00000X, 261QF0400X, 363A00000X, 363L00000X
OR124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022868Medicaid
OR022868Medicaid
OR381801Medicare Oscar/Certification