Basic Information
| Provider Information | |||||||||
| NPI: | 1164711933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEW SOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1653 ELK CIR SW | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973213734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035764568 | ||||||||
| FaxNumber: | 5033646552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035764568 | ||||||||
| FaxNumber: | 5033612782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POS | ||||||||
| AuthorizedOfficialFirstName: | TY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | WRAPAROUND FACILITATOR | ||||||||
| AuthorizedOfficialTelephone: | 5035764568 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | A5022 | OR | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.