Provider Demographics
NPI:1942632005
Name:KLAMATH CHILD NAD FAMILY TREATMENT CENTER
Entity Type:Organization
Organization Name:KLAMATH CHILD NAD FAMILY TREATMENT CENTER
Other - Org Name:KLAMATH YOUTH DEVELOPMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDALENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-883-1030
Mailing Address - Street 1:2210 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:541-884-2338
Practice Address - Street 1:725 WASHBURN WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3648
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:541-884-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid