Basic Information
| Provider Information | |||||||||
| NPI: | 1083641310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY FAMILY HEALTH CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836615420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086429376 | ||||||||
| FaxNumber: | 2086429376 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | NYSSA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979133815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413725738 | ||||||||
| FaxNumber: | 5413725732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2086429376 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY FAMILY HEALTH CARE, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 022827 | 05 | OR | MEDICAID | 002548600 | 05 | ID | MEDICAID | FQHC | 01 | OR | COMMUNITY HEALTH CENTER | OTHER |