Healthcare Provider Details

I. General information

NPI: 1811981053
Provider Name (Legal Business Name): COOS COUNTY OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 LACLAIR STREET
COOS BAY OR
97420
US

IV. Provider business mailing address

281 LACLAIR STREET
COOS BAY OR
97420
US

V. Phone/Fax

Practice location:
  • Phone: 541-266-6700
  • Fax: 541-888-8726
Mailing address:
  • Phone: 541-266-6700
  • Fax: 541-888-8726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name: DAWN RENEE BROUGHTON
Title or Position: ACCOUNTING SUPERVISOR
Credential:
Phone: 541-266-6716