Healthcare Provider Details

I. General information

NPI: 1235212986
Provider Name (Legal Business Name): VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-6513
US

IV. Provider business mailing address

1281 SE MAGNOLIA DR.
ROSEBURG OR
97470-6513
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax: 541-440-1273
Mailing address:
  • Phone: 541-440-1000
  • Fax: 541-440-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GEORGE MARNELL
Title or Position: DIRECTOR
Credential:
Phone: 541-440-1000