Provider Demographics
NPI:1407219157
Name:CRC HEALTH OREGON
Entity Type:Organization
Organization Name:CRC HEALTH OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ROSE ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:503-252-2949
Mailing Address - Street 1:6601 NE 78TH CT
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2823
Mailing Address - Country:US
Mailing Address - Phone:503-252-3949
Mailing Address - Fax:
Practice Address - Street 1:6185 PASEO DEL NORTE
Practice Address - Street 2:STE 150
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1152
Practice Address - Country:US
Practice Address - Phone:855-259-2288
Practice Address - Fax:760-918-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028382Medicaid