Basic Information
| Provider Information | |||||||||
| NPI: | 1669067369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERFALL CLINIC INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 WAITE STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974593409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 ELROD AVE | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | TRENNER | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5417566232 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WATERFALL CLINIC, INCORPORATED | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.