Basic Information
| Provider Information | |||||||||
| NPI: | 1548205354 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOUCHMARK LIVING CENTERS, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WATERFORD AT THREE FOUNTAINS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 SW GRIFFITH DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970052935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036465186 | ||||||||
| FaxNumber: | 5036465186 | ||||||||
| Practice Location | |||||||||
| Address1: | 835 CRATER LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417737717 | ||||||||
| FaxNumber: | 5418575139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRYOR | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5036465186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 385126 | OR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 800545 | 05 | OR | MEDICAID |