Provider Demographics
NPI:1659421295
Name:ABC HOUSE, INC.
Entity Type:Organization
Organization Name:ABC HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ASTIN
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-926-2203
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321
Mailing Address - Country:US
Mailing Address - Phone:541-926-2203
Mailing Address - Fax:541-926-1378
Practice Address - Street 1:228 SW 5TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-926-2203
Practice Address - Fax:541-926-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150785Medicaid