Basic Information
Provider Information | |||||||||
NPI: | 1225068505 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KLAMATH ALCOHOL & DRUG ABUSE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KLAMATH ALCOHOL & DRUG ABUSE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 310 S 5TH ST | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 976016108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418832795 | ||||||||
FaxNumber: | 5418500239 | ||||||||
Practice Location | |||||||||
Address1: | 310 S 5TH ST | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 976016108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418832795 | ||||||||
FaxNumber: | 5418500239 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEWEY | ||||||||
AuthorizedOfficialFirstName: | DEE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST II | ||||||||
AuthorizedOfficialTelephone: | 5418832795 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   | OR | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
No ID Information.