Provider Demographics
NPI:1891042487
Name:CLACKAMAS COUNTY
Entity Type:Organization
Organization Name:CLACKAMAS COUNTY
Other - Org Name:SUNNYSIDE 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 STE 367
Mailing Address - Street 2:
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 1:9775 SE SUNNYSIDE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5721
Practice Address - Country:US
Practice Address - Phone:503-794-3830
Practice Address - Fax:503-794-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
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
OR031799Medicaid
OR500653393Medicaid
OR131607Medicaid
OR022710Medicaid
ORR134087Medicare PIN
OR500653393Medicaid
OR381820Medicare Oscar/Certification
OR022710Medicaid