Provider Demographics
NPI:1396924999
Name:NORTHWEST RENAL CLINIC, INC.
Entity type:Organization
Organization Name:NORTHWEST RENAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HORSFALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-229-7976
Mailing Address - Street 1:1130 NW 22ND AVENUE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:9701 SW BARNES ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-595-6675
Practice Address - Fax:503-595-6679
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST RENAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-31
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119297Medicaid
OR119297Medicaid
R0000WCGSJMedicare PIN