Basic Information
Provider Information | |||||||||
NPI: | 1730663790 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LA CLINICA SCHOOL- BASED HEALTH CENTER AT PATRICK ELEMENTARY SCHOOL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 931 CHEVY WAY | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975044127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415356239 | ||||||||
FaxNumber: | 5418422212 | ||||||||
Practice Location | |||||||||
Address1: | 1500 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | GOLD HILL | ||||||||
State: | OR | ||||||||
PostalCode: | 975259728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414946818 | ||||||||
FaxNumber: | 5414946816 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2018 | ||||||||
LastUpdateDate: | 07/15/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEANNOT | ||||||||
AuthorizedOfficialFirstName: | TARA | ||||||||
AuthorizedOfficialMiddleName: | LYNETTE | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5415356239 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 022868 | 05 | OR |   | MEDICAID |