Basic Information
| Provider Information | |||||||||
| NPI: | 1609963842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIACARE SERVICES | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | DRIFTWOOD LODGE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Practice Location | |||||||||
| Address1: | 29413 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476566 | ||||||||
| FaxNumber: | 5412476549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECKETT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5418588170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 717 | OR | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 323P00000X | 717 | OR | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 513857 | 01 | OR | DW SERVICE PMT | OTHER | 276114 | 05 | OR | MEDICAID |