Basic Information
| Provider Information | |||||||||
| NPI: | 1619460227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CURRY HEALTH DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CURRY MEDICAL WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 94220 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412473000 | ||||||||
| FaxNumber: | 5412473159 | ||||||||
| Practice Location | |||||||||
| Address1: | 94125 FOURTH STREET | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476628 | ||||||||
| FaxNumber: | 5412476629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLCUTT | ||||||||
| AuthorizedOfficialFirstName: | SHELLIE | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5414122073 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CURRY HEALTH DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 14-0251 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OR | MEDICAID |