Basic Information
Provider Information | |||||||||
NPI: | 1528684354 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RSL WOODBURN, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10220 SW GREENBURG RD STE 201 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972235505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035952810 | ||||||||
FaxNumber: | 5035952818 | ||||||||
Practice Location | |||||||||
Address1: | 1890 NEWBERG HWY | ||||||||
Address2: |   | ||||||||
City: | WOODBURN | ||||||||
State: | OR | ||||||||
PostalCode: | 970713100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039824000 | ||||||||
FaxNumber: | 5039820139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2020 | ||||||||
LastUpdateDate: | 06/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GUFFEE | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OF MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5035952810 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RADIANT COMPANIES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X |   |   | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 525544 | 05 | OR |   | MEDICAID | 525545 | 05 | OR |   | MEDICAID | 1642094909 | 01 | OR | RESIDENTIAL CARE FACILITY LICENSE | OTHER |