Healthcare Provider Details

I. General information

NPI: 1356872477
Provider Name (Legal Business Name): VERNON ROSE JR. CADC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 W 11TH AVE
EUGENE OR
97402-5435
US

IV. Provider business mailing address

4211 W 11TH AVE
EUGENE OR
97402-5435
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-1577
  • Fax: 541-242-2853
Mailing address:
  • Phone: 541-485-1577
  • Fax: 541-242-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number07-09-64
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier07-09-64
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerCERTIFIED ALCOHOL AND DRUG COUNSELOR LEVEL II
# 2
Identifier500730386
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: