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Active
Organization subpart
No

Provider details

NPI number
Authorized official
MICKEL L LEWIS (ADMINISTRATOR/PROGRAM DIRECTOR)
(360) 665-4494
Entity
Organization

Contact information

Practice address
25517 PARK AVE., OCEAN PARK, WA 98640-0399
(360) 665-4494
(360) 665-6528
Mailing address
PO BOX 399, 25517 PARK AVENUE, OCEAN PARK, WA 98640-0399
(360) 665-4494
(360) 665-6528

Taxonomy

Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
RTF.FS.60221179
WA

Other

Enumeration date
02/06/2012
Last updated
02/06/2012
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