Basic Information
Provider Information | |||||||||
NPI: | 1508287871 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID-COLUMBIA CENTER FOR LIVING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCCFL ODELL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 419 E 7TH ST | ||||||||
Address2: | ANNEX A | ||||||||
City: | THE DALLES | ||||||||
State: | OR | ||||||||
PostalCode: | 970582676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412965452 | ||||||||
FaxNumber: | 5412969418 | ||||||||
Practice Location | |||||||||
Address1: | 3686 DAVIS DRIVE | ||||||||
Address2: |   | ||||||||
City: | HOOD RIVER | ||||||||
State: | OR | ||||||||
PostalCode: | 97031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412965452 | ||||||||
FaxNumber: | 5412969418 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2014 | ||||||||
LastUpdateDate: | 01/03/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SEATTER | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5412965452 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MID-COLUMBIA CENTER FOR LIVING | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | OR | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.