Provider Demographics
NPI:1982859393
Name:PIONEER GUEST HOME
Entity Type:Organization
Organization Name:PIONEER GUEST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:RODDEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSGT/ USMC RETIRED
Authorized Official - Phone:541-426-4222
Mailing Address - Street 1:101 E MAIN ST
Mailing Address - Street 2:P.O. BOX 326
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1381
Mailing Address - Country:US
Mailing Address - Phone:541-426-4222
Mailing Address - Fax:541-426-6550
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:BOX 326
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1381
Practice Address - Country:US
Practice Address - Phone:541-426-4222
Practice Address - Fax:541-426-6550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness