1669411377 NPI number — COLUMBIA RIVER MENTAL HEALTH SERVICES

Table of content: (NPI 1669411377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669411377 NPI number — COLUMBIA RIVER MENTAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA RIVER MENTAL HEALTH SERVICES
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:
1669411377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98666-1337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-993-3000
Provider Business Mailing Address Fax Number:
360-993-3047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6926 NE FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-993-3000
Provider Business Practice Location Address Fax Number:
360-993-3047
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
360-993-3000

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  138 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: 06 0894 00 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 06 0894 00 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 067 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1992775 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7117195 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06288 . This is a "REGENCE BCBS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1980705 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7035975 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9630716 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9234600 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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