Organization
PACIFIC CREST TRAIL DETOX LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BENJAMIN RANDOLPH MS, CADCIII (CEO)
(503) 901-1836
Entity
Organization
Contact information
Practice address
7708 SE CLACKAMAS RD, MILWAUKIE, OR 97267-4405
(503) 908-8875
Mailing address
10600 SE MCLOUGHLIN BLVD, 207, MILWAUKIE, OR 97222-7428
(855) 770-0577
(503) 654-1852
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
10/05/2016
Last updated
10/05/2016
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