Provider Demographics
NPI:1669067369
Name:WATERFALL CLINIC INCORPORATED
Entity type:Organization
Organization Name:WATERFALL CLINIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-756-6232
Mailing Address - Street 1:1890 WAITE STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3409
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:465 ELROD AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERFALL CLINIC, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)