Provider Demographics
NPI:1457681736
Name:PROJECT PATCH
Entity Type:Organization
Organization Name:PROJECT PATCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAGELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-690-8495
Mailing Address - Street 1:2404 E MILL PLAIN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4334
Mailing Address - Country:US
Mailing Address - Phone:360-690-8495
Mailing Address - Fax:360-690-8498
Practice Address - Street 1:25 MIRACLE LN
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622
Practice Address - Country:US
Practice Address - Phone:208-462-3074
Practice Address - Fax:208-462-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID26124323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility