Basic Information
| Provider Information | |||||||||
| NPI: | 1043335615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAINBOW FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CATHOLIC COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 20400 | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973070400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033902600 | ||||||||
| FaxNumber: | 5033908629 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 NE 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971284408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034722240 | ||||||||
| FaxNumber: | 5033908629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEYMOUR | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5033902600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CATHOLIC COMMUNITY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | LETTER OF APPROVAL | OR | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320900000X | LETTER OF APPROVAL | OR | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 261545 | 01 | OR | PROVIDER NUMBER | OTHER | 230442 | 01 | OR | PROVIDER NUMBER | OTHER |