Provider Demographics
NPI:1477708113
Name:LITHIA SPRINGS
Entity Type:Organization
Organization Name:LITHIA SPRINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-779-2393
Mailing Address - Street 1:201 W MAIN ST STE 3D
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2744
Mailing Address - Country:US
Mailing Address - Phone:541-779-2393
Mailing Address - Fax:541-779-3317
Practice Address - Street 1:695 MISTLETOE RD
Practice Address - Street 2:SUITE H
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-9552
Practice Address - Country:US
Practice Address - Phone:541-482-8906
Practice Address - Fax:541-779-3317
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY WORKS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-21
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127014Medicaid
OR164979Medicaid