Provider Demographics
NPI:1811981053
Name:COOS COUNTY OREGON
Entity type:Organization
Organization Name:COOS COUNTY OREGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-266-6716
Mailing Address - Street 1:281 LACLAIR STREET
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-266-6700
Mailing Address - Fax:541-888-8726
Practice Address - Street 1:281 LACLAIR STREET
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-266-6700
Practice Address - Fax:541-888-8726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOS COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-02
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X, 261QM0801X, 302R00000X
261QM0801X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500500169Medicaid
OR500602110Medicaid