Basic Information
| Provider Information | |||||||||
| NPI: | 1508934696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRILLIUM FAMILY SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TFS OF CENTRAL OREGON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032053577 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Practice Location | |||||||||
| Address1: | 63660 NW BRITTA ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977019475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184845 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JUSTICE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5032053577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OR | X | Agencies | Community/Behavioral Health | 320800000X | X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 213143 | 05 | OR | MEDICAID |