Basic Information
| Provider Information | |||||||||
| NPI: | 1760827182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN FARM HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4455 NE HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973309695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417571852 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | VAVE | ||||||||
| AuthorizedOfficialFirstName: | WALKER | ||||||||
| AuthorizedOfficialMiddleName: | COOK | ||||||||
| AuthorizedOfficialTitleorPosition: | SKILLS TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 5417585944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 101Y00000X | OR | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.