Provider Demographics
NPI:1124198999
Name:VA SOUTHERN OREGON
Entity Type:Organization
Organization Name:VA SOUTHERN OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DUAL-DIAGNOSIS THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:WOLFGANG
Authorized Official - Middle Name:LAURENCE
Authorized Official - Last Name:AGOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-826-2111
Mailing Address - Street 1:839 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1713
Mailing Address - Country:US
Mailing Address - Phone:541-261-8349
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility