Organization
CHILDREN'S COMMUNITY CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARDICA HICKS (CEO)
(503) 284-5239
Entity
Organization
Contact information
Practice address
2250 LLOYD CTR, PORTLAND, OR 97232-1311
(503) 284-5239
(503) 284-9162
Mailing address
2250 LLOYD CTR, PORTLAND, OR 97232-1311
(503) 284-5239
(503) 284-9162
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500612895
—
OR
Enumeration date
08/20/2007
Last updated
06/09/2021
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