Provider Demographics
NPI:1982197182
Name:POWER HOUSE DETOX
Entity Type:Organization
Organization Name:POWER HOUSE DETOX
Other - Org Name:PHD
Other - Org Type:Other Name
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:HOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II, CRM
Authorized Official - Phone:541-720-4636
Mailing Address - Street 1:3955 SALMON RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:OTIS
Mailing Address - State:OR
Mailing Address - Zip Code:97368-9778
Mailing Address - Country:US
Mailing Address - Phone:541-720-4636
Mailing Address - Fax:888-977-2106
Practice Address - Street 1:3955 SALMON RIVER HWY
Practice Address - Street 2:
Practice Address - City:OTIS
Practice Address - State:OR
Practice Address - Zip Code:97368-9778
Practice Address - Country:US
Practice Address - Phone:541-720-4636
Practice Address - Fax:888-977-2106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE POWER HOUSE RESIDENTIAL DRUG TREATMENT CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR700119276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667339Medicaid