Basic Information
| Provider Information | |||||||||
| NPI: | 1770776387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE PORLAND MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | PROVIDENCE HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 ENGLE AVE | ||||||||
| Address2: | |||||||||
| City: | MOLALLA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970389138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1503351019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4805 NE GLISAN ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032151111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | EELLS | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | RN/NURSE PRACTITIONER STUDENT | ||||||||
| AuthorizedOfficialTelephone: | 15032156150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 09000464RN | OR | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.