Basic Information
| Provider Information | |||||||||
| NPI: | 1932435377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF LINCOLN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LINCOLN COUNTY HEALTH & HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654179 | ||||||||
| FaxNumber: | 5415746252 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 NE EADS ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973652819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412659281 | ||||||||
| FaxNumber: | 5412658628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5412650434 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student 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 |