Basic Information
| Provider Information | |||||||||
| NPI: | 1497371025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FM PELICAN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7420 SW BRIDGEPORT RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035974906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 WASHBURN WAY | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976033685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418828900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2020 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | RODERICK | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5034431818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 527509 | 05 | OR | MEDICAID | 527434 | 05 | OR | MEDICAID |