Provider Demographics
NPI:1699535096
Name:SRIPONYA COLLECTIVE
Entity type:Organization
Organization Name:SRIPONYA COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:EALES
Authorized Official - Suffix:
Authorized Official - Credentials:CHW, PSS, JD
Authorized Official - Phone:541-408-0968
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-0052
Mailing Address - Country:US
Mailing Address - Phone:541-408-0968
Mailing Address - Fax:
Practice Address - Street 1:1080 SE BLUEGRASS LN
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1642
Practice Address - Country:US
Practice Address - Phone:541-408-0968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health