Provider Demographics
NPI:1588999007
Name:FOUR RIVERS HEALTHCARE CLINIC
Entity type:Organization
Organization Name:FOUR RIVERS HEALTHCARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:AILEEN
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-889-2244
Mailing Address - Street 1:640 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2625
Mailing Address - Country:US
Mailing Address - Phone:541-889-3510
Mailing Address - Fax:541-889-3510
Practice Address - Street 1:932 W IDAHO AVE STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2155
Practice Address - Country:US
Practice Address - Phone:541-889-2244
Practice Address - Fax:541-889-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550081NP363LP0808X
OR07904364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty