Basic Information
Provider Information | |||||||||
NPI: | 1760718100 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF LINCOLN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LINCOLN COUNTY HHS WALDPORT SBHC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36 SW NYE ST | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | OR | ||||||||
PostalCode: | 973653821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412654179 | ||||||||
FaxNumber: | 5415746252 | ||||||||
Practice Location | |||||||||
Address1: | 3000 S CRESTLINE DR | ||||||||
Address2: |   | ||||||||
City: | WALDPORT | ||||||||
State: | OR | ||||||||
PostalCode: | 973949739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412650471 | ||||||||
FaxNumber: | 5416505662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2009 | ||||||||
LastUpdateDate: | 04/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | VALERIE | ||||||||
AuthorizedOfficialMiddleName: | JEAN | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5412650434 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 213144 | 05 | OR |   | MEDICAID |