Healthcare Provider Details

I. General information

NPI: 1518180744
Provider Name (Legal Business Name): QUINAULT CHEMICAL DEPEDENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WA DR
TAHOLAH WA
98587-0219
US

IV. Provider business mailing address

PO BOX 219 1505 KLA-OOK-WA DR
TAHOLAH WA
98587
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-9991
Mailing address:
  • Phone: 360-276-4405
  • Fax: 360-276-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID A HAGEN
Title or Position: PROGRAM MANAGER
Credential: CDP
Phone: 360-276-4405