Basic Information
| Provider Information | |||||||||
| NPI: | 1366865495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAIROS NORTHWEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 TACOMA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975269370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414673302 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOLDT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5414745579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.