Provider Demographics
NPI:1801062179
Name:OAKRIDGE MEDICAL CLINIC
Entity type:Organization
Organization Name:OAKRIDGE MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:BENTS
Authorized Official - Last Name:NICOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-534-5135
Mailing Address - Street 1:4309 OAKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3418
Mailing Address - Country:US
Mailing Address - Phone:503-636-9687
Mailing Address - Fax:503-636-9680
Practice Address - Street 1:4309 OAKRIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3418
Practice Address - Country:US
Practice Address - Phone:503-636-9687
Practice Address - Fax:503-636-9680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09151261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR086264Medicaid