Basic Information
| Provider Information | |||||||||
| NPI: | 1821333402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA CLINICA SCHOOL-BASED HEALTH CENTER AT PHOENIX ELEMENTARY SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 215 N ROSE ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415351065 | ||||||||
| FaxNumber: | 5415122082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2012 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| 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. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 022868 | 05 | OR | MEDICAID |