Basic Information
Provider Information | |||||||||
NPI: | 1386787596 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIACARE SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CEDAR BAY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3587 HEATHROW WAY | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 97504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418588170 | ||||||||
FaxNumber: | 5418588167 | ||||||||
Practice Location | |||||||||
Address1: | 1592 MONROE ST | ||||||||
Address2: |   | ||||||||
City: | NORTH BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 974593657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417562048 | ||||||||
FaxNumber: | 5417562022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 05/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BECKETT | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5418588170 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 889 | OR | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
ID Information
ID | Type | State | Issuer | Description | 516824 | 01 | OR | CEDAR BAY SERVICE PAYMENT | OTHER | 213056 | 05 | OR |   | MEDICAID |