Basic Information
| Provider Information | |||||||||
| NPI: | 1093715070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLAMETTE VALLEY HOSPICE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLAMETTE VALLEY HOSPICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035883600 | ||||||||
| FaxNumber: | 5033633891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035883600 | ||||||||
| FaxNumber: | 5033633891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | DETHROW | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5037792308 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | N/A | OR | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 8008493 | 01 | OR | REGENCE | OTHER | 112347 | 01 | OR | KAISER PERMANENTE | OTHER | 132212 | 05 | OR | MEDICAID |