Healthcare Provider Details

I. General information

NPI: 1932554243
Provider Name (Legal Business Name): STRIDE RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2747 NEWTON ST
PHILOMATH OR
97370-9214
US

IV. Provider business mailing address

2747 NEWTON ST
PHILOMATH OR
97370-9214
US

V. Phone/Fax

Practice location:
  • Phone: 541-654-3709
  • Fax:
Mailing address:
  • Phone: 541-654-3709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number519136
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier519136
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: COLETTE LEE MARCHANT
Title or Position: OWNER
Credential:
Phone: 541-654-3709