Provider Demographics
NPI:1164676672
Name:UNIVERSITY PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:UNIVERSITY PROFESSIONAL SERVICES
Other - Org Name:CHILD DEVELOPMENT & REHABILITATION CENTER IN EUGENE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-494-1471
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-3800
Mailing Address - Fax:
Practice Address - Street 1:901 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1354
Practice Address - Country:US
Practice Address - Phone:503-494-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500606167Medicaid