Provider Demographics
NPI:1992238091
Name:MADRONA RECOVERY
Entity type:Organization
Organization Name:MADRONA RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:BRADY
Authorized Official - Last Name:BRAITHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-749-0200
Mailing Address - Street 1:7000 SW VARNS ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8145
Mailing Address - Country:US
Mailing Address - Phone:503-749-0200
Mailing Address - Fax:
Practice Address - Street 1:7000 SW VARNS ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8145
Practice Address - Country:US
Practice Address - Phone:949-293-2351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
OR324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility