Provider Demographics
NPI:1225329014
Name:COLUMBIACARE SERVICES
Entity Type:Organization
Organization Name:COLUMBIACARE SERVICES
Other - Org Name:CENTENIAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-858-8170
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:15208 SE TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2356
Practice Address - Country:US
Practice Address - Phone:503-760-0959
Practice Address - Fax:503-761-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200012320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR518374OtherCENTENIAL SERVICE PMT