Basic Information
| Provider Information | |||||||||
| NPI: | 1508133299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERFALL CLINIC, INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 WAITE ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2011 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCFERON | ||||||||
| AuthorizedOfficialFirstName: | AVA | ||||||||
| AuthorizedOfficialMiddleName: | KATHLEEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO ASST. | ||||||||
| AuthorizedOfficialTelephone: | 5414357033 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WATERFALL CLINIC, INCORPORATED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 500647633 | 05 | OR | MEDICAID |