Basic Information
| Provider Information | |||||||||
| NPI: | 1407178528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. CHARLES FAMILY CARE - PRINEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7287 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977087287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414478724 | ||||||||
| Practice Location | |||||||||
| Address1: | 384 SE COMBS FLAT RD | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414478724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2010 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELANDER | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5413824321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 500642552 | 05 | OR | MEDICAID |