1871801704 NPI number — TELECARE MENTAL HEATLH SERVICE OF OREGON, INC

Table of content: (NPI 1871801704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871801704 NPI number — TELECARE MENTAL HEATLH SERVICE OF OREGON, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELECARE MENTAL HEATLH SERVICE OF OREGON, INC
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:
1871801704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1080 MARINA VILLAGE PKWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ALAMEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94501-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-337-7950
Provider Business Mailing Address Fax Number:
510-337-7969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20370 POE SHOLES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-7938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-318-1377
Provider Business Practice Location Address Fax Number:
541-383-4587
Provider Enumeration Date:
09/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
LORENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER RELATIONS SUPERVISOR
Authorized Official Telephone Number:
510-337-7950

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500632287 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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