Provider Demographics
NPI:1700258258
Name:LA PINE KTC, LLC
Entity Type:Organization
Organization Name:LA PINE KTC, LLC
Other - Org Name:KLEAN LA PINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF BUSINESS DEVELOPMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-668-8008
Mailing Address - Street 1:16161 BURGESS RD
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-9533
Mailing Address - Country:US
Mailing Address - Phone:509-668-8008
Mailing Address - Fax:503-432-8913
Practice Address - Street 1:16161 BURGESS RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9533
Practice Address - Country:US
Practice Address - Phone:509-668-8008
Practice Address - Fax:503-432-8913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE RABBIT PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility