Provider Demographics
| NPI: | 1548087331 |
|---|---|
| Name: | ROSE CITY RECOVERY |
| Entity type: | Organization |
| Organization Name: | ROSE CITY RECOVERY |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | OWNER/PSS |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | RAHEEM |
| Authorized Official - Middle Name: | JAHMEL |
| Authorized Official - Last Name: | WATSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PSS/CRM |
| Authorized Official - Phone: | 480-881-4555 |
| Mailing Address - Street 1: | 610 SE 6TH AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PORTLAND |
| Mailing Address - State: | OR |
| Mailing Address - Zip Code: | 97214-2224 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 480-881-4555 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 610 SE 6TH AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | PORTLAND |
| Practice Address - State: | OR |
| Practice Address - Zip Code: | 97214-2224 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 480-881-4555 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2024-09-23 |
| Last Update Date: | 2025-06-04 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
| No | 174200000X | Other Service Providers | Meals | |
| No | 251B00000X | Agencies | Case Management | |
| No | 251S00000X | Agencies | Community/Behavioral Health | |
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
| No | 261QR0800X | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care |
| No | 275N00000X | Hospital Units | Medicare Defined Swing Bed Unit | |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
| No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
| No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances |
| No | 310500000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness | |
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OR | 1205663739 | Medicaid |
