Organization
OUTSIDE IN
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISS AMY DAWN MOORE (MEDICAL BILLING MANAGER)
(503) 535-3842
Entity
Organization
Contact information
Practice address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
(503) 535-3842
(503) 535-3842
Mailing address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
(503) 535-3842
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
181599
—
OR
Enumeration date
01/05/2018
Last updated
01/05/2018
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