Provider Demographics
NPI:1912322074
Name:MULTNOMAH COUNTY
Entity Type:Organization
Organization Name:MULTNOMAH COUNTY
Other - Org Name:CENTENNIAL SCHOOL BASE
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM BUSINESS SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-2966
Mailing Address - Street 1:619 NW 6TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:3505 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5028
Practice Address - Country:US
Practice Address - Phone:503-988-5488
Practice Address - Fax:503-988-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
ORR0000WCJHTMedicare Oscar/Certification