Provider Demographics
NPI:1174717573
Name:CASCADE FAMILY CARE PC
Entity type:Organization
Organization Name:CASCADE FAMILY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:503-581-6550
Mailing Address - Street 1:1095 LIBERTY ST NE
Mailing Address - Street 2:STE A
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1137
Mailing Address - Country:US
Mailing Address - Phone:503-581-6550
Mailing Address - Fax:503-581-4755
Practice Address - Street 1:1095 LIBERTY ST NE
Practice Address - Street 2:STE A
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1137
Practice Address - Country:US
Practice Address - Phone:503-581-6550
Practice Address - Fax:503-581-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150116NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210854Medicaid
ORS67194Medicare UPIN