Healthcare Provider Details

I. General information

NPI: 1720023807
Provider Name (Legal Business Name): DEPT. OF HUMAN SRVCS/OFFICE OF FIN. SRVCS DBA: IRS/EOPC/EOTC/OSH/OSH-P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 WESTGATE
PENDLETON OR
97801-9613
US

IV. Provider business mailing address

PO BOX 14900
SALEM OR
97309-5016
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-0820
  • Fax: 541-276-1147
Mailing address:
  • Phone: 503-945-9469
  • Fax: 503-947-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number6021
License Number StateOR

VIII. Authorized Official

Name: RUSSELL R. KITTRELL
Title or Position: INSTITUTIONAL REVENUE SECTION MGR.
Credential:
Phone: 503-945-9440