Basic Information
| Provider Information | |||||||||
| NPI: | 1528147782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARION COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARION COUNTY HEALTH DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 CENTER | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3180 CENTER | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | STACIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGEMENT ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 5035764589 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 122994 | 05 | OR | MEDICAID |