Basic Information
| Provider Information | |||||||||
| NPI: | 1114947942 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA LUTHERAN CHARITIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLUMBIA MEMORIAL HOSPITAL HOME HEALTH SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033254321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 486 12TH ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971034122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033386230 | ||||||||
| FaxNumber: | 5033386240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FINKLEIN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5033254321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH, MBA, CHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 141146 | OR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 05795800 | 01 | OR | BLUE CROSS | OTHER | 129218 | 05 | OR | MEDICAID |