Basic Information
| Provider Information | |||||||||
| NPI: | 1720023807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPT. OF HUMAN SRVCS/OFFICE OF FIN. SRVCS DBA: IRS/EOPC/EOTC/OSH/OSH-P | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASTERN OREGON TRAINING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14900 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973095016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039459469 | ||||||||
| FaxNumber: | 5039471007 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 WESTGATE | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978019613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412760820 | ||||||||
| FaxNumber: | 5412761147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KITTRELL | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | INSTITUTIONAL REVENUE SECTION MGR. | ||||||||
| AuthorizedOfficialTelephone: | 5039459440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | 6021 | OR | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 400093 | 05 | OR | MEDICAID |