1649895921 NPI number — CANBY ALF, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649895921 NPI number — CANBY ALF, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANBY ALF, 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:
RACKLEFF PLACE
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:
1649895921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15900 SE 82ND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-9502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-255-4647
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 SW 13TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANBY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97013-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-266-9555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VERDIECK
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP FINANCE & ADMINISTRATION
Authorized Official Telephone Number:
503-255-4647

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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