Provider Demographics
NPI:1184887523
Name:COUNTY OF TILLAMOOK
Entity type:Organization
Organization Name:COUNTY OF TILLAMOOK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:503-842-3900
Mailing Address - Street 1:801 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3926
Mailing Address - Country:US
Mailing Address - Phone:503-842-3900
Mailing Address - Fax:
Practice Address - Street 1:276 S HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:OR
Practice Address - Zip Code:97136-1015
Practice Address - Country:US
Practice Address - Phone:503-355-2700
Practice Address - Fax:503-355-2702
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TILLAMOOK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-07
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11776261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116488OtherNORIDIAN
OR128756Medicaid
OR116488OtherNORIDIAN