Basic Information
Provider Information | |||||||||
NPI: | 1083763239 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BESTCARE TREATMENT HISPANIC SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROGRAMA DE RECUPERACION | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 236 SE D ST | ||||||||
Address2: |   | ||||||||
City: | MADRAS | ||||||||
State: | OR | ||||||||
PostalCode: | 977411619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414755300 | ||||||||
FaxNumber: | 5414755310 | ||||||||
Practice Location | |||||||||
Address1: | 236 SE D ST | ||||||||
Address2: |   | ||||||||
City: | MADRAS | ||||||||
State: | OR | ||||||||
PostalCode: | 977411619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414755300 | ||||||||
FaxNumber: | 5414755310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TRELEAVEN | ||||||||
AuthorizedOfficialFirstName: | RICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5415049577 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW, CADCII | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | LETTER OF APPROVAL | OR | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 210831 | 05 | OR |   | MEDICAID |