MEDICARE: OREGON RECOVERY BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1164111472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON RECOVERY BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 20674
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97307-0674
Country	:	US
Telephone Number	:	503-304-4358
Fax Number	:

Provider Business Practice Location Address
First Line	:	147 SW COURT ST
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-3112
Country	:	US
Telephone Number	:	503-304-4358
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JUSTIN SCOTT NIELSEN
Credential	:	CADC II
Telephone Number	:	503-304-4358

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	12/15/2023

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