Basic Information
| Provider Information | |||||||||
| NPI: | 1891012506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRILLIUM FAMILY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Practice Location | |||||||||
| Address1: | 4455 NE HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973309695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | FOWELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE ASSURANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032053577 | ||||||||
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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 | 323P00000X | 0006 | OR | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 620225 | 05 | OR | MEDICAID |