Basic Information
| Provider Information | |||||||||
| NPI: | 1235172180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESCHUTES COUNTY OREGON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2577 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | INBODY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | GERARD | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH SERVICES DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5413227678 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 145789 | 05 | OR | MEDICAID | 500500013 | 05 | OR | MEDICAID | 170912 | 05 | OR | MEDICAID | 047621 | 05 | OR | MEDICAID | 500602527 | 05 | OR | MEDICAID | 184176 | 05 | OR | MEDICAID |