Provider Demographics
NPI:1083281034
Name:NEW FRIENDS OF COOS BAY, LLC
Entity Type:Organization
Organization Name:NEW FRIENDS OF COOS BAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-826-5190
Mailing Address - Street 1:25260 SW PARKWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6627
Mailing Address - Country:US
Mailing Address - Phone:503-826-5190
Mailing Address - Fax:
Practice Address - Street 1:955 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-6807
Practice Address - Country:US
Practice Address - Phone:541-808-9730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR528759Medicaid