Basic Information
| Provider Information | |||||||||
| NPI: | 1699921296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORVALLIS CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 NW ELKS DR | ||||||||
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| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417541150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3680 NW SAMARITAN DR | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417541150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2008 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | KAECH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5417541374 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORVALLIS CLINIC PC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 38D0656873 | OR | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 276671 | 05 | OR | MEDICAID | 276663 | 05 | OR | MEDICAID | 276697 | 05 | OR | MEDICAID | 299481 | 05 | OR | MEDICAID |