Provider Demographics
NPI:1386714053
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-826-2111
Mailing Address - Street 1:307 GANGNES DR
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-6655
Mailing Address - Country:US
Mailing Address - Phone:541-535-1773
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:541-830-7485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAA426809261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health