Provider Demographics
NPI:1548928583
Name:LOPER, OLIVIA (CHW)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:LOPER
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63140 BRITTA ST STE D104
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-5738
Mailing Address - Country:US
Mailing Address - Phone:866-931-3414
Mailing Address - Fax:
Practice Address - Street 1:442 SW UMATILLA AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-7039
Practice Address - Country:US
Practice Address - Phone:866-931-3414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR105871172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000105871Medicaid