Basic Information
| Provider Information | |||||||||
| NPI: | 1962966184 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLAMATH HEALTH PARTNERSHIP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3013 SUMMERS LANE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976019760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | JEANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CPES | ||||||||
| AuthorizedOfficialTelephone: | 5418802011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KLAMATH HEALTH PARTNERSHIP, INC | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 170061 | 05 | OR | MEDICAID |