Healthcare Provider Details

I. General information

NPI: 1750462230
Provider Name (Legal Business Name): PREVENTION AND RECOVERY NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 OLIVE ST
EUGENE OR
97401-3547
US

IV. Provider business mailing address

1188 OLIVE ST
EUGENE OR
97401-3547
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-9274
  • Fax: 541-484-5021
Mailing address:
  • Phone: 541-484-9274
  • Fax: 541-484-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier165165
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: ANN-MARIE BILDERBACK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-484-9274