Basic Information
| Provider Information | |||||||||
| NPI: | 1215347109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVERTON HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEGACY MEDICAL GROUP BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4037 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731500 | ||||||||
| FaxNumber: | 5038731534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1475 MT. HOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9719835214 | ||||||||
| FaxNumber: | 9719835219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOFF | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.