Provider Demographics
NPI:1912061755
Name:ADAPT
Entity Type:Organization
Organization Name:ADAPT
Other - Org Name:SOUTHRIVER MEDICAL CLINIC AKA: SOUTHRIVER COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-492-4550
Mailing Address - Street 1:P.O BOX 12
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-0012
Mailing Address - Country:US
Mailing Address - Phone:541-492-4550
Mailing Address - Fax:541-492-4553
Practice Address - Street 1:671 SW MAIN
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-0012
Practice Address - Country:US
Practice Address - Phone:541-492-4550
Practice Address - Fax:541-492-4553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADAPT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QF0400X
OR276245261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007151Medicaid
OR007151Medicaid
OR381919Medicare UPIN