Provider Demographics
NPI:1629168166
Name:ADOLESCENT DAY TREATMENT CENTER INC OF DOUGLAS COUNTY
Entity Type:Organization
Organization Name:ADOLESCENT DAY TREATMENT CENTER INC OF DOUGLAS COUNTY
Other - Org Name:RIVERSIDE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-679-6129
Mailing Address - Street 1:PO BOX 2259
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-2259
Mailing Address - Country:US
Mailing Address - Phone:541-679-6129
Mailing Address - Fax:541-679-5285
Practice Address - Street 1:671 S.W. MAIN
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496
Practice Address - Country:US
Practice Address - Phone:541-679-6129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCERTIFCATE OF APPROV261QM0801X
ORCERTIFICATE APPROVAL261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297927Medicaid
OR297928Medicaid