Basic Information
| Provider Information | |||||||||
| NPI: | 1528628898 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EUGENIA CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1371 | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985320340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 N MARKET BLVD | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | FABIOLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3602665585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EUGENIA CENTER | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1009072 | 05 | WA | MEDICAID |