1194980615 NPI number — INNOVATIVE SENIOR CARE HOME HEALTH OF PORTLAND LLC

Table of content: (NPI 1194980615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194980615 NPI number — INNOVATIVE SENIOR CARE HOME HEALTH OF PORTLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE SENIOR CARE HOME HEALTH OF PORTLAND 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:
6
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:
1194980615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-443-4154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7750 SW MOHAWK STREET
Provider Second Line Business Practice Location Address:
BLDG G, SUITE 7750
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-9191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-582-9246
Provider Business Practice Location Address Fax Number:
503-685-9047
Provider Enumeration Date:
07/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PROFFITT
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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