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General NPI Number Information
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NPI Number | 1235212986
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Entity Type | Organization
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Legal Business Name | VA
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 913 NW GARDEN VALLEY BLVD
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City | ROSEBURG
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State | OR
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Zip | 97470-6513
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Country | US
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Telephone | 541-440-1000
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Fax | 541-440-1273
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Provider Business Mailing Address
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Address Line | 1281 SE MAGNOLIA DR.
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City | ROSEBURG
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State | OR
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Zip | 97470-6513
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Country | US
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Telephone | 541-440-1000
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Fax | 541-440-1273
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Authorized Official
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Title or Position | DIRECTOR
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Name | GEORGE MARNELL
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Credential |
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Telephone | 541-440-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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