Provider Demographics
NPI:1457735615
Name:COASTLINE CORVALLIS CLINIC LLC
Entity Type:Organization
Organization Name:COASTLINE CORVALLIS CLINIC LLC
Other - Org Name:COASTLINE FOOT AND ANKLE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-370-8784
Mailing Address - Street 1:1829 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1907
Mailing Address - Country:US
Mailing Address - Phone:541-757-7100
Mailing Address - Fax:541-757-7101
Practice Address - Street 1:1829 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1907
Practice Address - Country:US
Practice Address - Phone:541-757-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTLINE FOOT AND ANKLE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-16
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP154513261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR164712Medicaid