Provider Demographics
NPI:1174698971
Name:CHRISTIAN COMMUNITY PLACEMENT CENTER
Entity type:Organization
Organization Name:CHRISTIAN COMMUNITY PLACEMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBOHRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-588-5647
Mailing Address - Street 1:4890 32ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317
Mailing Address - Country:US
Mailing Address - Phone:503-588-5647
Mailing Address - Fax:503-588-0509
Practice Address - Street 1:4890 32ND AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317
Practice Address - Country:US
Practice Address - Phone:503-588-5647
Practice Address - Fax:503-779-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0056253J00000X
OR322D00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240040Medicaid