Provider Demographics
NPI:1356438592
Name:COLUMBIACARE SERVICES
Entity type:Organization
Organization Name:COLUMBIACARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-858-8170
Mailing Address - Street 1:1175 E MAIN ST
Mailing Address - Street 2:1B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7499
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:1885 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2152
Practice Address - Country:US
Practice Address - Phone:541-266-8480
Practice Address - Fax:541-266-8479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR545385H00000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR312033Medicaid