Healthcare Provider Details

I. General information

NPI: 1083281034
Provider Name (Legal Business Name): NEW FRIENDS OF COOS BAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 KENTUCKY AVE
COOS BAY OR
97420-6807
US

IV. Provider business mailing address

25260 SW PARKWAY AVE STE B
WILSONVILLE OR
97070-6627
US

V. Phone/Fax

Practice location:
  • Phone: 541-808-9730
  • Fax:
Mailing address:
  • Phone: 503-826-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier528759
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: CARL MASON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 503-826-5190