Basic Information
| Provider Information | |||||||||
| NPI: | 1134495039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST LINN CARE CENTER OPERATING COMPANY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20300 S SOUTH END RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970457700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037060878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2330 DEBOK RD | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036550474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | WALDROFF | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5037060878 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1565662204 | OR | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 38E018 | 05 | OR | MEDICAID |