Healthcare Provider Details

I. General information

NPI: 1538320528
Provider Name (Legal Business Name): COOS COUNTY CORRECTIONAL TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 MCPHERSON ST
NORTH BEND OR
97459-3482
US

IV. Provider business mailing address

PO BOX 849
NORTH BEND OR
97459-0070
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-2020
  • Fax: 541-756-4401
Mailing address:
  • Phone: 541-756-2020
  • Fax: 541-756-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KELLY CHURCH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 541-396-3173