Provider Demographics
NPI:1942946934
Name:COUNTY OF LINCOLN
Entity type:Organization
Organization Name:COUNTY OF LINCOLN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-265-0445
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-0468
Mailing Address - Fax:
Practice Address - Street 1:525 N BAY ST
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394-9010
Practice Address - Country:US
Practice Address - Phone:541-265-4947
Practice Address - Fax:541-574-7670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF LINCOLN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-11
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251S00000XAgenciesCommunity/Behavioral Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213144Medicaid