Provider Demographics
NPI:1881010502
Name:OREGON TRAIL RECOVERY LLC
Entity Type:Organization
Organization Name:OREGON TRAIL RECOVERY LLC
Other - Org Name:CLEAN ADVENTURES OF OREGON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-901-1836
Mailing Address - Street 1:10600 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:STE 207
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10600 SE MCLOUGHLIN BLVD
Practice Address - Street 2:STE 207
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7428
Practice Address - Country:US
Practice Address - Phone:503-901-1836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder