Provider Demographics
NPI:1447031679
Name:PRAIRIE BLOOM CENTER FOR GROWTH INC
Entity type:Organization
Organization Name:PRAIRIE BLOOM CENTER FOR GROWTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MEXICOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-556-9665
Mailing Address - Street 1:1029 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3242
Mailing Address - Country:US
Mailing Address - Phone:541-556-9665
Mailing Address - Fax:
Practice Address - Street 1:1029 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3242
Practice Address - Country:US
Practice Address - Phone:541-556-9665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty