Provider Demographics
NPI:1942503248
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:CENTRAL POINT HEALTH CENTER- LA CLINICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA
Authorized Official - Phone:541-512-3151
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 1:4940 HAMRICK ROAD
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-3072
Practice Address - Country:US
Practice Address - Phone:541-690-3600
Practice Address - Fax:541-664-3735
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-09
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
OR022868Medicaid
OR022868Medicaid
OR381801Medicare Oscar/Certification