Provider Demographics
NPI:1417192972
Name:WALLOWA VALLEY CENTER FOR WELLNESS
Entity Type:Organization
Organization Name:WALLOWA VALLEY CENTER FOR WELLNESS
Other - Org Name:WALLOWA RIVER HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KLIEWER
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN, MSW
Authorized Official - Phone:541-426-4524
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0268
Mailing Address - Country:US
Mailing Address - Phone:541-426-4524
Mailing Address - Fax:541-426-3035
Practice Address - Street 1:601 WHISKEY CREEK RD
Practice Address - Street 2:
Practice Address - City:WALLOWA
Practice Address - State:OR
Practice Address - Zip Code:97885-7129
Practice Address - Country:US
Practice Address - Phone:541-886-3142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR984320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213546Medicaid