Basic Information
| Provider Information | |||||||||
| NPI: | 1629008651 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARBOR CARE REEDWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3540 SE FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023350 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3540 SE FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032325767 | ||||||||
| FaxNumber: | 5032344162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 12/28/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LESTER | ||||||||
| AuthorizedOfficialFirstName: | MARCUS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5032325767 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 800091 | OR | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 313M00000X | 800091 | OR | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 800091 | 05 | OR | MEDICAID |