Provider Demographics
NPI:1619397767
Name:COFFEE CREEK CORRECTION FACILITY
Entity Type:Organization
Organization Name:COFFEE CREEK CORRECTION FACILITY
Other - Org Name:TURNING POINT PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:503-238-0769
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:503-963-7711
Practice Address - Street 1:847 NE 19TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2684
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:503-963-7711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASCADIA BEHAVIORAL HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty