Basic Information
| Provider Information | |||||||||
| NPI: | 1487908935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHANGRI-LA CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OLD OAK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4080 REED RD SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811732 | ||||||||
| FaxNumber: | 5033162299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1206 OLD OAK DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973226655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419268207 | ||||||||
| FaxNumber: | 5419265781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 11/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HONEY | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5035811732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | OR | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 516706 | 01 | OR | DMAP PROVIDER # | OTHER |