Provider Demographics
NPI:1174352975
Name:MADRONA RECOVERY WASHINGTON LLC
Entity type:Organization
Organization Name:MADRONA RECOVERY WASHINGTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
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:PORTLAND
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 1:11910 NE 154TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9571
Practice Address - Country:US
Practice Address - Phone:503-749-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility