Provider Demographics
NPI:1932323474
Name:WINDING WATERS CLINIC PC
Entity type:Organization
Organization Name:WINDING WATERS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-886-2431
Mailing Address - Street 1:406 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1168
Mailing Address - Country:US
Mailing Address - Phone:541-886-2431
Mailing Address - Fax:541-886-2211
Practice Address - Street 1:203 E FIRST STREET
Practice Address - Street 2:
Practice Address - City:WALLOWA
Practice Address - State:OR
Practice Address - Zip Code:97885-9999
Practice Address - Country:US
Practice Address - Phone:541-886-2431
Practice Address - Fax:541-886-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
OR383865261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223198Medicaid
OR5966000OtherBCBS PROVIDER NUMBER
ORCG2920OtherMEDICARE RAILROAD
OR223198Medicaid
ORR0000WCGFJMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER