LIFE RENEWAL - SHEDD OUTPATIENT
Complete NPI Record 1245784222
Community/Behavioral Health in Milwaukie, OR
Active since August 08, 2016
Complete NPI Dataset
This page contains the complete raw NPPES record for Life Renewal - Shedd Outpatient (NPI 1245784222), a community/behavioral health organization in Milwaukie, OR. All 53 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1245784222 Field 1/53
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/53
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/53
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: TEEN CHALLENGE INTERNATIONAL PACIFIC NORTHWEST CENTERS Field 4/53
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider Other Organization Name: LIFE RENEWAL - SHEDD OUTPATIENT Field 5/53
- Other name by which the organization provider is or has been known.
- Provider Other Organization Name Type Code: 3 Field 6/53
- Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
- Provider First Line Business Mailing Address: 18600 SE MCLOUGHLIN BLVD Field 7/53
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: MILWAUKIE Field 8/53
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: OR Field 9/53
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 972676723 Field 10/53
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 11/53
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 9712550658 Field 12/53
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider First Line Business Practice Location Address: 18600 SE MCLOUGHLIN BLVD Field 13/53
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: MILWAUKIE Field 14/53
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: OR Field 15/53
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 972676723 Field 16/53
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 17/53
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 9712550658 Field 18/53
- The telephone number associated with the location address of the provider being identified.
- Authorized Official Last Name: NELSON Field 21/53
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: BRIAN Field 22/53
- The first name of the authorized official.
- Authorized Official Title or Position: COO Field 23/53
- The title or position of the authorized official.
- Authorized Official Telephone Number: 9712550658 Field 24/53
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 101YA0400X Field 25/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: N Field 26/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 101YM0800X Field 27/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 2: N Field 28/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 3: 171M00000X Field 29/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 3: N Field 30/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 4: 261QM0801X Field 31/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 4: N Field 32/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 5: 261QR0405X Field 33/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 5: N Field 34/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 6: 251S00000X Field 35/53
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 6: Y Field 36/53
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 500711843 Field 37/53
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 05 Field 38/53
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: OR Field 39/53
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 2: 90591 Field 40/53
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 05 Field 41/53
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 2: MT Field 42/53
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 3: 1712386 Field 43/53
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 05 Field 44/53
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 3: AK Field 45/53
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 4: 2173185 Field 46/53
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 4: 05 Field 47/53
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 4: WA Field 48/53
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Is Organization Subpart: N Field 49/53
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP Field 50/53
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
- Healthcare Provider Taxonomy Group 2: 193200000X MULTI-SPECIALTY GROUP Field 51/53
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
- Healthcare Provider Taxonomy Group 3: 193200000X MULTI-SPECIALTY GROUP Field 52/53
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
Other Organization Names 1
Additional business and trade names this provider has on file with the NPPES registry.
Life Renewal - Portland Outpatient Doing Business As
Name 1/1Doing Business As: A trade name or operating name under which an organization provides services, distinct from its registered legal business name.
Secondary Practice Locations 12
The first line of the secondary practice location address of the provider being identified. For providers with more than one physical location, this is a secondary practice location address. This address cannot include a Post Office box.
401 NE Burnside Ave
Location 1/12Bend, OR 97701-5122 · Phone (541) 797-0098 · Fax (971) 236-8080
380 NW 6th Ave
Location 2/12Estacada, OR 97023-7713 · Phone (503) 230-1910
5040 SE 82nd Ave
Location 3/12Portland, OR 97266-4802 · Phone (503) 395-0435 · Fax (971) 236-8080
31700 Fayetteville Dr
Location 4/12Shedd, OR 97377-9779 · Phone (541) 491-1002 ext. 11002
1600 N 20th Ave Ste A
Location 5/12Pasco, WA 99301-3376 · Phone (509) 537-3025 · Fax (971) 236-8080
2400 N Craig Rd
Location 6/12Spokane, WA 99224-9568 · Phone (509) 606-6563 · Fax (971) 236-8080
545 S Knik Goose Bay Rd
Location 7/12Wasilla, AK 99654-8171 · Phone (907) 268-4686 · Fax (971) 236-8080
21115 92nd Ave E Ste A
Location 8/12Graham, WA 98338-8088 · Phone (253) 846-0888
3815 S 7th St W
Location 9/12Missoula, MT 59804-1915 · Phone (406) 540-7001 · Fax (971) 236-8080
5351 King Ave W
Location 10/12Billings, MT 59106-2821 · Phone (406) 272-7220 · Fax (971) 236-8080
18611 148th Ave SE
Location 11/12Renton, WA 98058-9312 · Phone (425) 226-2608 ext. 3380
224 Martin St
Location 12/12Twin Falls, ID 83301-4542 · Phone (208) 543-7230
Other Provider Identifiers 4
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
500711843 Medicaid
Identifier 1/4State: OR
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
90591 Medicaid
Identifier 2/4State: MT
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
1712386 Medicaid
Identifier 3/4State: AK
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
2173185 Medicaid
Identifier 4/4State: WA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
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