Healthcare Provider Details

I. General information

NPI: 1174352975
Provider Name (Legal Business Name): MADRONA RECOVERY WASHINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11910 NE 154TH ST
BRUSH PRAIRIE WA
98606-9571
US

IV. Provider business mailing address

7000 SW VARNS ST
PORTLAND OR
97223-8145
US

V. Phone/Fax

Practice location:
  • Phone: 503-749-2000
  • Fax:
Mailing address:
  • Phone: 503-749-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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