Provider Demographics
NPI:1588046791
Name:BENTON COUNTY
Entity type:Organization
Organization Name:BENTON COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLLEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-766-6835
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0579
Mailing Address - Country:US
Mailing Address - Phone:541-766-6190
Mailing Address - Fax:541-766-6164
Practice Address - Street 1:435 E ALDER ST
Practice Address - Street 2:
Practice Address - City:ALSEA
Practice Address - State:OR
Practice Address - Zip Code:97324-9634
Practice Address - Country:US
Practice Address - Phone:541-487-7116
Practice Address - Fax:541-487-4076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENTON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-24
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227701Medicaid
OR0000WCHSCMedicare PIN