Provider Demographics
NPI:1710903968
Name:SOUTHERN OREGON REHABILITATION CENTER AND CLINICS
Entity Type:Organization
Organization Name:SOUTHERN OREGON REHABILITATION CENTER AND CLINICS
Other - Org Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RECREATION THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAGNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-826-2111
Mailing Address - Street 1:8495 CRATER LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-3011
Mailing Address - Country:US
Mailing Address - Phone:541-826-2111
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility