Healthcare Provider Details

I. General information

NPI: 1962800300
Provider Name (Legal Business Name): FRESH START FAMILY SERVICES OF OREGON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8825 SE 42ND AVE
MILWAUKIE OR
97222-5568
US

IV. Provider business mailing address

8825 SE 42ND AVE
MILWAUKIE OR
97222-5568
US

V. Phone/Fax

Practice location:
  • Phone: 503-704-4579
  • Fax: 971-245-3416
Mailing address:
  • Phone: 503-704-4579
  • Fax: 971-245-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number0295
License Number StateOR

VIII. Authorized Official

Name: SUSAN DIANE SHEETS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 503-704-4579