Basic Information
| Provider Information | |||||||||
| NPI: | 1649691981 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-COLUMBIA CENTER FOR LIVING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MCCFL THE DALLES LINCOLN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| 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: | 409 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970581809 | ||||||||
| 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.