Provider Demographics
NPI:1285178210
Name:FOOTHILLS MEDICAL SUPPLY, LLC
Entity type:Organization
Organization Name:FOOTHILLS MEDICAL SUPPLY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-496-5239
Mailing Address - Street 1:8440 SE SUNNYBROOK BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5781
Mailing Address - Country:US
Mailing Address - Phone:503-496-5239
Mailing Address - Fax:503-343-6554
Practice Address - Street 1:200 HAWTHORNE AVE SE STE A130
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0074
Practice Address - Country:US
Practice Address - Phone:503-496-5239
Practice Address - Fax:503-343-6554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1687801-4332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115951Medicaid
OR1285178210Medicaid
7225360001Medicare NSC