Basic Information
| Provider Information | |||||||||
| NPI: | 1386706919 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARION COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARION COUNTY HEALTH AND HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 CENTER ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885358 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2045 SILVERTON RD NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAO | ||||||||
| AuthorizedOfficialFirstName: | TRUCMAI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5033612648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 190702 | 05 | OR | MEDICAID |