Basic Information
| Provider Information | |||||||||
| NPI: | 1679073712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBACARE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT RESIDENTIAL SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 57TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974786821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2018 | ||||||||
| LastUpdateDate: | 02/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | SEWITSKY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5418588170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.