Provider Demographics
NPI:1750372579
Name:DOMINICAN HEALTH SERVICES
Entity type:Organization
Organization Name:DOMINICAN HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-881-7020
Mailing Address - Street 1:351 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2639
Mailing Address - Country:US
Mailing Address - Phone:541-881-7020
Mailing Address - Fax:541-881-7186
Practice Address - Street 1:1118 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2271
Practice Address - Country:US
Practice Address - Phone:208-452-6851
Practice Address - Fax:541-881-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00189759321500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134054Medicaid
IDE8340OtherBCID GROUP
ID8053332-00Medicaid
ORX-009702000OtherBLUE CROSS OF OREGON
ORX-009702000OtherBLUE CROSS OF OREGON
ID8053332-00Medicaid