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Active NPI 1104787704 Organization (Entity Type 2)

Pacificsource Pace, Llc

Program of All-Inclusive Care for the Elderly (PACE) Provider Organization • Springfield, OR

About Pacificsource Pace, Llc NPI 1104787704 Summary

Pacificsource Pace, Llc is a verified healthcare organization specializing in Program of All-Inclusive Care for the Elderly (PACE) Provider Organization operating in Springfield, OR. Located at 555 INTERNATIONAL WAY STE B104, this facility provides patient care and medical services under National Provider Identifier (NPI) 1104787704.

Administrative operations and authorized compliance are overseen by Kristin Kernutt (Chief Legal Counsel).

Facility Location & Contact Primary Location

Facility Address

555 International Way Ste B104

Springfield, OR 974776013

Telephone 4585440400

Authorized Official Information

Authorized Contact Name

Kristin Kernutt , JD

Title / Role

Chief Legal Counsel

Official Telephone

5412251967

Facility Classifications & Specialties

Program of All-Inclusive Care for the Elderly (PACE) Provider Organization Primary Taxonomy

NUCC Taxonomy Code: 251T00000X

A PACE provider organization is a not-for-profit private or public entity that is primarily engaged in providing PACE services(unique capitated managed care benefits for the frail elderly which include comprehensive medical and social services). The following characteristics also apply to a PACE organization. It must: have a governing board that includes community representation; be able to provide complete PACE services regardless of frequency or duration of services; have a physical site to provide adult day services; have a defined service area; have safeguards against conflict of interest; have demonstrated fiscal soundness and have a formal Participant Bill of Rights.

Facility & Registry History Timeline

Chronological log of verified NPI organization updates, branch relocations, and registry updates

6 Historical Events
NPI Profile Active November 21, 2025

NPI status registered as active in NPPES database

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Updated Practice Location November 21, 2025

Registered at 555 INTERNATIONAL WAY STE B104, SPRINGFIELD, OR 974776013 (Tel: 4252142526)

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Updated Business Mailing Address November 21, 2025

Registered at 555 INTERNATIONAL WAY STE B104, SPRINGFIELD, OR 974776013 (Tel: 4252142526)

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Organization / Clinic Name Updated November 21, 2025

Operating as PACIFICSOURCE PACE, LLC

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Medical Taxonomy / Specialty Registered (Primary Specialty) November 21, 2025

Program of All-Inclusive Care for the Elderly (PACE) Provider Organization

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Initial NPI Registration & Enumeration November 21, 2025

First registered as active Healthcare Organization in NPPES Database.

Patient & Community Reviews

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NPI Organization Metadata

NPI Number: 1104787704
Entity Type:
Organization Organization (Hospital, Clinic, Group Practice) (Type 2 NPI)
Enumeration Date: November 21, 2025
Last Update: July 16, 2026

Mailing Address

555 International Way Ste B104

Springfield, OR 974776013

Phone: 4585440400

Public Domain Record This organization profile is sourced from public domain datasets published by CMS and NPPES under FOIA.
⚠️ Medical Disclaimer

Facility details are provided for public information only. In case of a medical emergency, call 911 immediately.