Provider Demographics
NPI:1912152570
Name:64TH AVE LLC
Entity Type:Organization
Organization Name:64TH AVE LLC
Other - Org Name:KING RD RTF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHOENBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-786-3830
Mailing Address - Street 1:4199 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5892
Mailing Address - Country:US
Mailing Address - Phone:503-786-3830
Mailing Address - Fax:503-653-3534
Practice Address - Street 1:4199 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5892
Practice Address - Country:US
Practice Address - Phone:503-786-3830
Practice Address - Fax:503-653-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR869320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness