Basic Information
| Provider Information | |||||||||
| NPI: | 1578864641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLAMATH TRIBAL HEALTH & FAMILY SERVICES | ||||||||
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| OtherOrganizationName: | KLAMATH YOUTH REGIONAL TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3949 SOUTH 6TH ST. | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976034746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418821670 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 IOWA ST. | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418821670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 11/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | LEROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEALTH GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5418821487 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KLAMATH TRIBAL HEALTH & FAMILY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.