1629127584 NPI number — UMATILLA COUNTY ALCOHOL & DRUG PROGRAM

Table of content: DR. DOMINIQUE BOONE TARBER PSY.D (NPI 1861872343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629127584 NPI number — UMATILLA COUNTY ALCOHOL & DRUG PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UMATILLA COUNTY ALCOHOL & DRUG PROGRAM
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:
1629127584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 SE HAILEY AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
PENDLETON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97801-3073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-278-6330
Provider Business Mailing Address Fax Number:
541-278-5419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 SE HAILEY AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801-3073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-278-6330
Provider Business Practice Location Address Fax Number:
541-278-5419
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MASON
Authorized Official First Name:
CR
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM ADMINISTRATION
Authorized Official Telephone Number:
541-278-6330

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , 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)

  • Identifier: 184028 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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