Provider Demographics
NPI:1932915063
Name:ROSE CITY DRUG & ALCOHOL DETOX CENTER OF PORTLAND LLC
Entity type:Organization
Organization Name:ROSE CITY DRUG & ALCOHOL DETOX CENTER OF PORTLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ OWNERSHIP
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CIP
Authorized Official - Phone:503-896-8232
Mailing Address - Street 1:10505 SW BARBUR BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6853
Mailing Address - Country:US
Mailing Address - Phone:503-896-8232
Mailing Address - Fax:
Practice Address - Street 1:12711 SE HOLGATE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3734
Practice Address - Country:US
Practice Address - Phone:503-896-8232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility