TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-6 For payment of services provided on or after October 1, 1998. NOTE: This listing is for residential treatment center per diem rates only. It does not reflect a facility s status as a TRICARE-authorized residential treatment center. Information regarding a facility s current status as an authorized provider can be obtained from the appropriate contractor. ALABAMA Hill Crest BHS-AL 6869 Fifth Avenue South Birmingham, AL 35212 EIN: 63-0862148 ARIZONA Wendy Paine O Brien Treatment Center 5055 North 34th St. Phoenix, AZ 85018 EIN: 86-0096778 Westbridge Treatment Center 1830 E. Roosevelt Phoenix, AZ 85006 EIN: 73-1195649 ARKANSAS BHC Pinnacle Pointe Hospital RTC, Inc. 11501 Financial Center Parkway Little Rock, AR 72211 EIN: 62-1658502 CALIFORNIA Broad Horizons P.O. Box 1920 1236 H Street Ramona, CA 92065 EIN: 62-1451701 BHC San Luis Rey Hospital, Inc. 335 Saxony Road Encinitas, CA 92024 EIN: 62-1658510 425.00 525.00 454.00 A6-1
APPENDIX A-6 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 San Diego Center for Children 3002 Armstrong Street P.O. Box 11024 San Diego, CA 92111 EIN: 95-1661089 Vista San Diego Center 3003 Armstrong Street San Diego, CA 92111 EIN: 95-1944230 COLORADO Brockhurst Extended Care Program P.O. Box 7021 825 E. Pikes Peak Colorado Springs, CO 80903 EIN: 84-0405257 Cedar Springs Hospital, Inc. 2135 Southgate Road Colorado Springs, CO 80906 EIN: 84-1209539 FLORIDA Valuemark Behavioral Healthcare System of Florida 6601 Central Florida Parkway Orlando, FL 32821 EIN: 58-2156425 Charter BHS at Manatee Palms, LP 4480 51st Street, West Bradenton, FL 34201 EIN: 65-0734879 Tampa Bay Academy 12012 Boyette Road Riverview, FL 33569 EIN: 52-1955335 BHC St. Johns River Hospital, Inc. 6300 Beach Blvd. Jacksonville, FL 32216 EIN: 62-1658514 Sandypines 11301 S.E. Tequesta Terrace Tequesta, FL 33469 EIN: 65-0425888 393.00 416.00 471.00 415.00 423.00 359.00 A6-2
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-6 GEORGIA Charter BHS of Atlanta at Laurel Heights, LLC 934 Briarcliff Road, N.E. Atlanta, GA 30306 EIN: 58-2301698 Charter Augusta BHS, LLC 3100 Perimeter Parkway Augusta, GA 30909 EIN: 58-2298592 Inner Harbour Hospitals, LTD. 4685 Dorsett Shoals Road Douglasville, GA 30135 EIN: 58-0873694 HAWAII Sutter Health Pacific DBA Kahi Mohala 912301 Fort Weaver Road Ewa Beach, HI 96706 EIN: 99-0298651 IDAHO BHC Intermountain Hospital, Inc. 303 N. Allumbaugh Street Boise, ID 83704 EIN: 62-1658493 INDIANA Charter BHS of Indiana at Jefferson, LLC 2700 River City Park Road Jeffersonville, IN 47130 EIN: 35-2010005 KANSAS BHC College Meadows Hospital, Inc. 14425 College Boulevard Lenexa, KS 66215 EIN: 62-1658526 The Menninger Clinic 5800 S.W. Sixth Avenue P.O. Box 829 Topeka, KS 66601 EIN: 48-1036688 506.00 538.00 349.00 358.00 524.00 A6-3
APPENDIX A-6 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 St. Francis at Salina, Inc. 5097 West Cloud Street Salina, KS 67401 EIN: 48-1033387 LOUISIANA DePaul/Tulane Residential Treatment Center 1040 Calhoun Street New Orleans, LA 70118 EIN: 62-1596506 MISSISSIPPI BHC Sand Hill Hospital, Inc. 11150 Highway 49 North Gulfport, MS 39503 EIN: 62-1658511 MISSOURI Crittenton Center 10918 Elm Avenue Kansas City, MO 64134 EIN: 44-0545808 Piney Ridge Center, Inc. 1000 Hospital Road P.O. Box 4067 Waynesville, MO 65583 EIN: 43-1521295 NEVADA BHC Willow Springs Center 690 Edison Way Reno, NV 89502 EIN: 88-0300031 NEW MEXICO Desert Hills Center- New Mexico 5310 Sequoia, N.W. Albuquerque, NM 87120 EIN: 74-2753620 NORTH CAROLINA Cumberland Hospital 3425 Melrose Road P.O. Box 42308 (28309) Fayetteville, NC 28304 EIN: 56-0845796 286.00 437.00 224.00 503.00 452.00 A6-4
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-6 OHIO BHC Belmont Pines Hospital, Inc. 615 Churchill - Hubbard Road Youngstown, OH 44505 EIN: 62-1658523 OKLAHOMA Shadow Mountain Hospital, Inc. 6262 South Sheridan Tulsa, OK 74133 EIN: 73-1449306 TENNESSEE Charter Lakeside BHS, LLC 2911 Brunswick Road P.O. Box 341308 Memphis, TN 38133 EIN: 62-1683156 TEXAS BHC Cedar Crest 3500 South IH 35 Belton, TX 76513 EIN: 74-2669474 CRC of San Antonio 17720 Corporate Woods Drive San Antonio, TX 78259 EIN: 74-2720152 Healthcare Rehabilitation Center of Austin Box 43148 1106 West Dittmar Austin, TX 78745 EIN: 74-2461514 Laurel Ridge Treatment Center 17720 Corporate Woods Drive P.O. Box 700590 San Antonio, TX 78259 EIN: 74-2388827 Meridell Achievement Center 12550 W Hwy 29 P.O. Box 87 Liberty Hill, TX 78642 EIN 74-1655289 305.00 328.00 488.00 488.00 456.00 A6-5
APPENDIX A-6 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 San Marcos Treatment Center Bert Brown Road P.O. Box 768 San Marcos, TX 78667 EIN: 74-2467014 Southwest Mental Health Center 8538 Tom Slick Drive San Antonio, TX 78229 EIN: 74-1153067 The Oaks Treatment Center 1407 West Stassney Lane Austin, TX 78745 EIN: 74-2416121 Quest Hospital Adolescent RTC 7200 West 9th Avenue Amarillo, TX 79106 EIN: 75-2180841 UTAH BHC Olympus View Hospital, Inc. 1430 East 4500 South Salt Lake City, UT 84117 EIN: 62-1658501 VERMONT Brattleboro Retreat-Tyler RTC 75 Linden Street Brattleboro, VT 05302 EIN: 03-0107360 VIRGINIA Charter Westbrook BHS, LLC 1500 Westbrook Avenue PO Box 9127 Richmond, VA 23227 EIN: 54-1841642 Poplar Springs Hospital 350 Poplar Drive P.O. Box 3060 Petersburg, VA 23805 EIN: 54-1819979 Valuemark - West End BHS 12800 West Creek Pkwy Richmond, VA 23238 EIN: 58-2156548 495.00 455.00 321.00 360.00 407.00 510.00 A6-6
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-6 The Pines Treatment Center 825 Crawford Parkway Portsmouth, VA 23704 EIN: 54-1465094 WASHINGTON Tamarack Center 2901 West Fort George Wright Spokane, WA 99204 EIN: 91-1216841 Overlake Hospital Medical Center 1035 116th Avenue NE Bellevue, WA 98004 EIN: 91-0652651 438.00 434.00 A6-7