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General NPI Number Information
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NPI Number | 1508357146
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Entity Type | Organization
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Legal Business Name | REDWOOD RECOVERY CENTER
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Dates
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Enumeration Date | 05/18/2018
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 717 NE 61ST ST STE 102
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City | VANCOUVER
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State | WA
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Zip | 98665-8755
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Country | US
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Telephone | 360-523-2997
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Fax |
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Provider Business Mailing Address
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Address Line | 717 NE 61ST ST STE 102
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City | VANCOUVER
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State | WA
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Zip | 98665-8755
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Country | US
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Telephone | 360-523-2997
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CRYSTAL KOSTRIVAS
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Credential |
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Telephone | 262-565-8938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 200568
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License Number State | WA
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