Provider Demographics
NPI:1104022649
Name:CHILDREN'S FARM HOME
Entity Type:Organization
Organization Name:CHILDREN'S FARM HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CATS1
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SIRAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-409-8666
Mailing Address - Street 1:31490 RABBIT RUN LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-8920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9695
Practice Address - Country:US
Practice Address - Phone:541-757-1852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health