Basic Information
Provider Information | |||||||||
NPI: | 1093085573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBLES | ||||||||
FirstName: | ALMA | ||||||||
MiddleName: | DELIA | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3469 DENVER PARK | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 97603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412812121 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 711 RAMSEY AVE | ||||||||
Address2: |   | ||||||||
City: | GRANTS PASS | ||||||||
State: | OR | ||||||||
PostalCode: | 97527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414795901 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2011 | ||||||||
LastUpdateDate: | 12/30/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 200642822RN | OR | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 101YMO800X | 01 | OR | SOASTC | OTHER |