Provider Demographics
NPI: | 1245378546 |
---|---|
Name: | FORA HEALTH INC. |
Entity Type: | Organization |
Organization Name: | FORA HEALTH INC. |
Other - Org Name: | DE PAUL TREATMENT CENTERS, INC. |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | CONTRACT COORDINATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MALLORY |
Authorized Official - Middle Name: | JUANITA-ANN |
Authorized Official - Last Name: | JOHNSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 503-535-1156 |
Mailing Address - Street 1: | P.O.BOX 16040 |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97292 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-535-1150 |
Mailing Address - Fax: | 503-535-1190 |
Practice Address - Street 1: | 10230 SE CHERRY BLOSSOM DR |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97216 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-535-1150 |
Practice Address - Fax: | 503-535-1190 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-01 |
Last Update Date: | 2022-07-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 101YA0400X, 101YM0800X, 261QM0801X, 261QM0850X, 261QR0401X, 261QR0405X, 320800000X, 324500000X, 3245S0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Single Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Single Specialty |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
No | 261QR0401X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | Group - Single Specialty |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Single Specialty |
No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | ||
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | ||
No | 3245S0500X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 299811 | Medicaid |