Provider Demographics
NPI:1518180744
Name:QUINAULT CHEMICAL DEPEDENCY
Entity Type:Organization
Organization Name:QUINAULT CHEMICAL DEPEDENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:360-276-4405
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:1505 KLA-OOK-WA DR
Mailing Address - City:TAHOLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98587
Mailing Address - Country:US
Mailing Address - Phone:360-276-4405
Mailing Address - Fax:360-276-9991
Practice Address - Street 1:1505 KLA-OOK-WA DR
Practice Address - Street 2:
Practice Address - City:TAHOLAH
Practice Address - State:WA
Practice Address - Zip Code:98587-0219
Practice Address - Country:US
Practice Address - Phone:360-276-4405
Practice Address - Fax:360-276-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1992817Medicaid