1144267667 NPI number — TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH LLC

Table of content: (NPI 1144267667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144267667 NPI number — TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144267667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 SW GRIFFITH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97005-2935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-646-5186
Provider Business Mailing Address Fax Number:
503-644-3568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2909 SE VILLAGE LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98683-8108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-254-2866
Provider Business Practice Location Address Fax Number:
360-883-3103
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRYOR
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
503-646-5186

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  011429 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50D1049339 . This is a "CLIA LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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