Provider Demographics
NPI:1881850386
Name:CORVALLIS CLINIC PC
Entity Type:Organization
Organization Name:CORVALLIS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KAECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-754-1374
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:601 NW ELKS DRIVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3781
Practice Address - Country:US
Practice Address - Phone:541-754-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORVALLIS CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-04
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043158Medicaid
OR500600864Medicaid
OR043158Medicaid
ORR135970Medicare PIN