Provider Demographics
NPI:1902622921
Name:ACTIVE INDEPENDENCE OREGON
Entity type:Organization
Organization Name:ACTIVE INDEPENDENCE OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBOEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-219-0122
Mailing Address - Street 1:3929 NE 78TH AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6400
Mailing Address - Country:US
Mailing Address - Phone:507-219-0122
Mailing Address - Fax:
Practice Address - Street 1:3929 NE 78TH AVE APT 12
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-6400
Practice Address - Country:US
Practice Address - Phone:507-219-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services