Provider Demographics
NPI:1043760838
Name:PACIFIC CREST TRAIL DETOX LLC
Entity Type:Organization
Organization Name:PACIFIC CREST TRAIL DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CADCIII
Authorized Official - Phone:503-901-1836
Mailing Address - Street 1:10600 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:207
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7428
Mailing Address - Country:US
Mailing Address - Phone:855-770-0577
Mailing Address - Fax:503-654-1852
Practice Address - Street 1:7708 SE CLACKAMAS RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-4405
Practice Address - Country:US
Practice Address - Phone:503-908-8875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility