Basic Information
| Provider Information | |||||||||
| NPI: | 1972556496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKIMA VALLEY FARM WORKERS CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SALUD MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989480190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039822000 | ||||||||
| FaxNumber: | 5039820660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 MOUNT HOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970719060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039822000 | ||||||||
| FaxNumber: | 5039820660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLIVARES | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | CARLOS | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5098656175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YAKIMA VALLEY FARM WORKERS CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 022793 | 05 | OR | MEDICAID |