Basic Information
| Provider Information | |||||||||
| NPI: | 1225226004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. CHARLES HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 470 NE A STREET | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414753882 | ||||||||
| FaxNumber: | 5414754804 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 NE A STREET | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414753882 | ||||||||
| FaxNumber: | 5414754804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEPARD | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5417067707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 141473 | OR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 045344 | 05 | OR | MEDICAID |