1861863409 NPI number — KLAMATH CHILD AND FAMILY TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861863409 NPI number — KLAMATH CHILD AND FAMILY TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KLAMATH CHILD AND FAMILY TREATMENT CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861863409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13907 RAVENWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97601-9591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-892-4655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2210 N ELDORADO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97601-6418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-883-1030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MENDOZA
Authorized Official First Name:
KARENA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
RESIDENT CARE AID
Authorized Official Telephone Number:
541-892-4655

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  93-0753926 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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