1164979191 NPI number — STONEYBROOKE RESIDENTIAL SERVICES, LLC

Table of content: (NPI 1164979191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164979191 NPI number — STONEYBROOKE RESIDENTIAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEYBROOKE RESIDENTIAL SERVICES, 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:
Provider Other Organization Name Type Code:
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:
1164979191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25500 SE STARK ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GRESHAM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97030-3331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-669-7191
Provider Business Mailing Address Fax Number:
503-669-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25500 SE STARK ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-3331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-669-7191
Provider Business Practice Location Address Fax Number:
503-669-7102
Provider Enumeration Date:
09/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
STONEY
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
503-669-7191

Provider Taxonomy Codes

  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com