Healthcare Provider Details

I. General information

NPI: 1992238091
Provider Name (Legal Business Name): MADRONA RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SW VARNS ST
TIGARD OR
97223-8145
US

IV. Provider business mailing address

7000 SW VARNS ST
TIGARD OR
97223-8145
US

V. Phone/Fax

Practice location:
  • Phone: 949-293-2351
  • Fax:
Mailing address:
  • Phone: 503-749-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateOR

VIII. Authorized Official

Name: MICAH BRADY BRAITHWAITE
Title or Position: COO/CFO
Credential:
Phone: 503-749-0200