Provider Demographics
NPI:1831196302
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 2724
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2724
Mailing Address - Country:US
Mailing Address - Phone:503-215-4601
Mailing Address - Fax:503-215-4624
Practice Address - Street 1:570 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOUNT ANGEL
Practice Address - State:OR
Practice Address - Zip Code:97362-9540
Practice Address - Country:US
Practice Address - Phone:503-845-9226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-30
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276701Medicaid
38-7074Medicare UPIN