Provider Demographics
NPI:1265672893
Name:SUNNYBROOK - ADDICTION MEDICINE
Entity type:Organization
Organization Name:SUNNYBROOK - ADDICTION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:
Authorized Official - First Name:VALEREE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:503-957-1906
Mailing Address - Street 1:3216 SE 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2010
Mailing Address - Country:US
Mailing Address - Phone:503-957-1906
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility