Healthcare Provider Details

I. General information

NPI: 1457681736
Provider Name (Legal Business Name): PROJECT PATCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MIRACLE LN # 450
GARDEN VALLEY ID
83622-1044
US

IV. Provider business mailing address

PO BOX 820209
VANCOUVER WA
98682-0004
US

V. Phone/Fax

Practice location:
  • Phone: 208-462-3074
  • Fax: 208-462-3209
Mailing address:
  • Phone: 360-690-8495
  • Fax: 360-690-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number26124
License Number StateID

VIII. Authorized Official

Name: CHUCK A HAGELE
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 360-690-8495