Healthcare Provider Details

I. General information

NPI: 1184983173
Provider Name (Legal Business Name): ROYAL AVE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 W 4TH AVE
EUGENE OR
97401-2505
US

IV. Provider business mailing address

780 HIGHWAY 99 N
EUGENE OR
97402-2301
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1262
  • Fax: 541-686-0359
Mailing address:
  • Phone: 541-686-1262
  • Fax: 541-686-1262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier233701
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: ERIN BONNER
Title or Position: ASSISTANT EXECTIVE DIRECTOR
Credential:
Phone: 541-686-1262