Healthcare Provider Details

I. General information

NPI: 1356438592
Provider Name (Legal Business Name): COLUMBIACARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 THOMPSON RD
COOS BAY OR
97420-2152
US

IV. Provider business mailing address

1175 E MAIN ST 1B
MEDFORD OR
97504-7499
US

V. Phone/Fax

Practice location:
  • Phone: 541-266-8480
  • Fax: 541-266-8479
Mailing address:
  • Phone: 541-858-8170
  • Fax: 541-858-8167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number545
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number545
License Number StateOR

VIII. Authorized Official

Name: MR. ROBERT C BECKETT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-858-8170