=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194297671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILVER LINING TREATMENT CENTER (DBA) RECOVERY BLVD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2018
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10209 SE DIVISION ST BLDG D
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97266-1372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-875-2787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1316 SE 12TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-875-2787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AUTUMN M BROWN
-----------------------------------------------------
Credential | MS, CADCIII
-----------------------------------------------------
Telephone | 503-875-2787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------