Basic Information
| Provider Information | |||||||||
| NPI: | 1508427428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-COLUMBIA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | NICHOLS LANDING MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967504 | ||||||||
| FaxNumber: | 5412967619 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 NICHOLS PKWY | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970313121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413081015 | ||||||||
| FaxNumber: | 5413081016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2019 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | TASHA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5415065710 | ||||||||
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| 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 |
No ID Information.