Basic Information
| Provider Information | |||||||||
| NPI: | 1801254644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENSON WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3930 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183900 | ||||||||
| FaxNumber: | 5034183938 | ||||||||
| Practice Location | |||||||||
| Address1: | 546 NE 12TH AVE | ||||||||
| Address2: | ROOM 126 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | GRUEBER | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM SR VP, EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5034941450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.