- Enrollment id
- O20061222000295
- Enrollment state
- OR
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1790873461
- Multiple npi flag
- N
- Ccn
- 387048
- Associate id
- 6305755000
- Organization name
- PROVIDENCE HEALTH & SERVICES OREGON
- Doing business as name
- PROVIDENCE HOME HEALTH
- Incorporation date
- 1934-02-20
- Incorporation state
- OR
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- N
- Address line 1
- 6410 NE HALSEY ST
- Address line 2
- STE 200
- City
- PORTLAND
- State
- OR
- Zip code
- 972134742
- Practice location type
- HHA BRANCH