Provider Demographics
NPI:1760796130
Name:PROJECT PATCH
Entity Type:Organization
Organization Name:PROJECT PATCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALINA
Authorized Official - Middle Name:B
Authorized Official - Last Name:POLOVINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-228-7106
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:GARDENVALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622
Mailing Address - Country:US
Mailing Address - Phone:360-690-8495
Mailing Address - Fax:
Practice Address - Street 1:2404 E MILL PLAIN BLVD STE 4
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4334
Practice Address - Country:US
Practice Address - Phone:360-690-8495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility