Provider Demographics
NPI:1356192652
Name:BYWATER HEALTH, LLC
Entity type:Organization
Organization Name:BYWATER HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:504-434-9164
Mailing Address - Street 1:2119 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1522
Mailing Address - Country:US
Mailing Address - Phone:503-975-9398
Mailing Address - Fax:503-221-8320
Practice Address - Street 1:2119 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1522
Practice Address - Country:US
Practice Address - Phone:503-975-9398
Practice Address - Fax:503-221-8320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty