Provider Demographics
NPI:1982792537
Name:GRANT COUNTY PREVENTION AND RECOVERY CENTER
Entity Type:Organization
Organization Name:GRANT COUNTY PREVENTION AND RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/COUNTY COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-765-5402
Mailing Address - Street 1:PO BOX 1217
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-0185
Mailing Address - Country:US
Mailing Address - Phone:509-765-5402
Mailing Address - Fax:509-766-2589
Practice Address - Street 1:1525 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-9753
Practice Address - Country:US
Practice Address - Phone:509-765-5402
Practice Address - Fax:509-766-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1990282Medicaid