Provider Demographics
NPI:1396172375
Name:KLAMATH YOUTH DEVELOPMENT CENTER
Entity type:Organization
Organization Name:KLAMATH YOUTH DEVELOPMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRANSITION CORDINATOR SBS
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CADC I
Authorized Official - Phone:541-591-5604
Mailing Address - Street 1:2210 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:
Practice Address - Street 1:2210 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6418
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid