Provider Demographics
NPI:1023562147
Name:WEST LINN CLEMENTINE, INC
Entity type:Organization
Organization Name:WEST LINN CLEMENTINE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-663-1876
Mailing Address - Street 1:6100 SW 76TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5002
Mailing Address - Country:US
Mailing Address - Phone:305-663-1876
Mailing Address - Fax:
Practice Address - Street 1:1148 ROSEMONT RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9235
Practice Address - Country:US
Practice Address - Phone:971-249-8448
Practice Address - Fax:503-305-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health