Provider Demographics
NPI:1720890262
Name:MULTNOMAH COUNTY
Entity type:Organization
Organization Name:MULTNOMAH COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-2966
Mailing Address - Street 1:619 NW 6TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3991
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:
Practice Address - Street 1:5530 NE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-1408
Practice Address - Country:US
Practice Address - Phone:503-988-3129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTNOMAH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid