Basic Information
| Provider Information | |||||||||
| NPI: | 1548999667 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINE STREET OPEN DOOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 403 PINE ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | JEANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RO | ||||||||
| AuthorizedOfficialTelephone: | 5418802011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KLAMATH HEALTH PARTNERSHIP, INC | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
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 | R101150 | 01 | OR | MEDICARE-B | OTHER | 170061 | 05 | OR | MEDICAID |