Provider Demographics
NPI:1639125156
Name:RENAISSANCE RECOVERY RESOURCES, INC.
Entity Type:Organization
Organization Name:RENAISSANCE RECOVERY RESOURCES, INC.
Other - Org Name:OREGON RECOVERY BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II
Authorized Official - Phone:503-304-4358
Mailing Address - Street 1:PO BOX 20674
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0674
Mailing Address - Country:US
Mailing Address - Phone:503-304-4358
Mailing Address - Fax:503-304-4361
Practice Address - Street 1:3793 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4827
Practice Address - Country:US
Practice Address - Phone:503-304-4358
Practice Address - Fax:503-304-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182192Medicaid