Healthcare Provider Details

I. General information

NPI: 1235646266
Provider Name (Legal Business Name): D & K HARBICK FIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91804 MILL CREEK RD
BLUE RIVER OR
97413-9711
US

IV. Provider business mailing address

91804 MILL CREEK RD
BLUE RIVER OR
97413-9711
US

V. Phone/Fax

Practice location:
  • Phone: 541-822-3603
  • Fax:
Mailing address:
  • Phone: 541-822-3603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAIL L HARBICKQ
Title or Position: OWNER
Credential:
Phone: 541-822-3603