1407219157 NPI number — CRC HEALTH OREGON

Table of content: (NPI 1407219157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407219157 NPI number — CRC HEALTH OREGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRC HEALTH OREGON
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:
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:
1407219157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6601 NE 78TH CT
Provider Second Line Business Mailing Address:
SUITE A-3
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97218-2823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-252-3949
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6185 PASEO DEL NORTE
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92011-1152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-259-2288
Provider Business Practice Location Address Fax Number:
760-918-8712
Provider Enumeration Date:
03/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
ROSE ANN
Authorized Official Title or Position:
NURSE SUPERVISOR
Authorized Official Telephone Number:
503-252-2949

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 028382 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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