Basic Information
| Provider Information | |||||||||
| NPI: | 1326003773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECOVERY ROAD INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PACIFIC RIDGE RESIDENTIAL ALCOHOL AND DRUG TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1587 PACIFIC RIDGE LANE SE | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033617758 | ||||||||
| FaxNumber: | 5035818292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1587 PACIFIC RIDGE LANE SE | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033617758 | ||||||||
| FaxNumber: | 5035818292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGENBERG | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5033617758 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | OR | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.