Provider Demographics
NPI:1841317237
Name:WHITE RIVER HEALTH DISTRICT
Entity type:Organization
Organization Name:WHITE RIVER HEALTH DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEHART
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:541-395-2911
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:MAUPIN
Mailing Address - State:OR
Mailing Address - Zip Code:97037-0219
Mailing Address - Country:US
Mailing Address - Phone:541-395-2911
Mailing Address - Fax:541-395-2912
Practice Address - Street 1:1605 GEORGE JACKSON RD
Practice Address - Street 2:
Practice Address - City:MAUPIN
Practice Address - State:OR
Practice Address - Zip Code:97037-9208
Practice Address - Country:US
Practice Address - Phone:541-395-2911
Practice Address - Fax:541-395-2912
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE RIVER HEALTH DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
ORPA00762363AM0700X
ORMD17484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006335Medicaid
ORR138203Medicare PIN
OR006335Medicaid
138203Medicare PIN