Basic Information
| Provider Information | |||||||||
| NPI: | 1942946934 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF LINCOLN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 N BAY ST | ||||||||
| Address2: | |||||||||
| City: | WALDPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973949010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2022 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | LESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5412650445 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.