Provider Demographics
NPI:1326414087
Name:INACTIVE - COUNTY OF LINCOLN
Entity type:Organization
Organization Name:INACTIVE - COUNTY OF LINCOLN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-265-0445
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-0468
Mailing Address - Fax:541-265-0443
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365
Practice Address - Country:US
Practice Address - Phone:541-265-4112
Practice Address - Fax:541-265-4194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165098Medicaid
OR213144Medicaid
OR213144Medicaid
OR165098Medicaid
OR381966Medicare Oscar/Certification