=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982160503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COFFEE OASIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2019
-----------------------------------------------------
Last Update Date | 02/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 837 4TH ST
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98337-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-377-5560
-----------------------------------------------------
Fax | 360-377-5560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 837 4TH ST
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98337-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-377-5560
-----------------------------------------------------
Fax | 360-377-5560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRISIS RESPONSE TEAM MANAGER
-----------------------------------------------------
Name | JOSHUA JOHN WILLIAM GOSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-377-5560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------