Basic Information
| Provider Information | |||||||||
| NPI: | 1770196016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CLINICA DEL VALLE FAMILY HEALTHCARE CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 931 CHEVY WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415356239 | ||||||||
| FaxNumber: | 5418422212 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 N. ROSE STREET | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415353287 | ||||||||
| FaxNumber: | 5415122082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | FOSSEN | ||||||||
| AuthorizedOfficialFirstName: | TRACI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF QUALITY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5415123912 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LA CLINICA DEL VALLE FAMILY HEALTHCARE CENTER INC. | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
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.