Basic Information
| Provider Information | |||||||||
| NPI: | 1285621268 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHERWOOD PARK NURSING HOME INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHERWOOD PARK NURSING AND REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4062 ARLETA AVE NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033902271 | ||||||||
| FaxNumber: | 5033900177 | ||||||||
| Practice Location | |||||||||
| Address1: | 4062 ARLETA AVE NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033902271 | ||||||||
| FaxNumber: | 5033900177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREDRICKSON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTORE OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5033902271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | OR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 804815 | 05 | OR | MEDICAID |