Provider Demographics
NPI:1922102128
Name:PINE EAGLE HEALTH PLANNING COMMITTEE
Entity Type:Organization
Organization Name:PINE EAGLE HEALTH PLANNING COMMITTEE
Other - Org Name:DBA-PINE EAGLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-742-5024
Mailing Address - Street 1:P.O. BOX 647
Mailing Address - Street 2:
Mailing Address - City:HALFWAY
Mailing Address - State:OR
Mailing Address - Zip Code:97834
Mailing Address - Country:US
Mailing Address - Phone:541-742-5023
Mailing Address - Fax:541-742-7210
Practice Address - Street 1:218 NORTH PINE STREET
Practice Address - Street 2:
Practice Address - City:HALFWAY
Practice Address - State:OR
Practice Address - Zip Code:97834
Practice Address - Country:US
Practice Address - Phone:541-742-5023
Practice Address - Fax:541-742-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR383869261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009919000OtherBLUE CROSS BLUE SHIELD
ORR139059OtherMEDICARE B
OR025069Medicaid
OR381812Medicare Oscar/Certification
OR383869Medicare Oscar/Certification