NPIMap

Organization Active NPI

Coastline Corvallis Clinic LLC

  • Ambulatory Surgical Clinic/Center
  • Corvallis, OR
National Provider Identifier
1457735615
Registry record updated Mar 10, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
License
DP154513 Issued in OR
Legal business name
COASTLINE CORVALLIS CLINIC LLC
Practice address
1829 NW Kings Blvd
Corvallis, OR 97330-1907
Phone
(541) 757-7100
NPI assigned
Jul 16, 2015
Organization subpart
Yes
Parent organization
COASTLINE FOOT AND ANKLE CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 10, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Linzie Gomez
Title
Manager
Phone
(503) 370-8784

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X DP154513 OR Primary

Addresses

Primary practice location

1829 NW Kings Blvd
Corvallis, OR 97330-1907

Mailing address

1829 NW Kings Blvd
Corvallis, OR 97330-1907
Phone (541) 757-7100

Other identifiers 1

IdentifierTypeStateIssuer
R164712MedicaidOR

Other names 1

  • Coastline Foot and Ankle Center Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20201021000675 OR Part B Supplier - Clinic/Group Practice 5799105300 Receives reassigned benefits from 1 practitioner
Practice locations: Corvallis, OR
O20220627001651 OR DME Supplier - Physician - Podiatry 5799105300 Practice locations: Corvallis, OR

National Provider Directory

National Provider Directory
Tax ID family
R Tyson Scott DPM LLC2 organizations share this tax ID, including this one
Part of
R Tyson Scott DPM LLC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1829 NW Kings Blvd
Corvallis, OR 97330
Phone (541) 752-5048

800 Liberty St SE
Salem, OR 97302
Phone (503) 370-8784

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1437004800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583798400000",
    "number": "1457735615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1829 NW KINGS BLVD",
            "city": "CORVALLIS",
            "state": "OR",
            "postal_code": "973301907",
            "telephone_number": "541-757-7100",
            "fax_number": "541-757-7101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1829 NW KINGS BLVD",
            "city": "CORVALLIS",
            "state": "OR",
            "postal_code": "973301907",
            "telephone_number": "541-757-7100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTLINE CORVALLIS CLINIC LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COASTLINE FOOT AND ANKLE CLINIC",
        "enumeration_date": "2015-07-16",
        "last_updated": "2020-03-10",
        "certification_date": "2020-03-10",
        "status": "A",
        "authorized_official_last_name": "GOMEZ",
        "authorized_official_first_name": "LINZIE",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "503-370-8784"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "OR",
            "license": "DP154513",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "R164712",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Coastline Foot and Ankle Center",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Corvallis, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.