Healthcare Provider Details

I. General information

NPI: 1629801543
Provider Name (Legal Business Name): CHRONICLES OF SUCCESS RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 JUANIPERO WAY STE 101
MEDFORD OR
97504-8647
US

IV. Provider business mailing address

5441 S MACADAM AVE STE N
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-0336
  • Fax: 541-508-0330
Mailing address:
  • Phone: 866-674-3347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DONIQUE BOAZEMAN
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 313-977-2767