Provider Demographics
NPI:1891061784
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:EAST MEDFORD DENTAL CLINIC-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 1:1113 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-512-3900
Practice Address - Fax:541-414-1175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-26
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0022868Medicaid
OR381916Medicare Oscar/Certification
OR0022868Medicaid