Basic Information
| Provider Information | |||||||||
| NPI: | 1629372040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOUCHMARK AT MEADOW LAKE VILLAGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 SW GRIFFITH DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970052935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036465186 | ||||||||
| FaxNumber: | 5036443568 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 S ARBOR LN | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836423025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088843308 | ||||||||
| FaxNumber: | 2088889381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2010 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | PRYOR | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5036465186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HH160 | ID | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HH160 | 01 | ID | STATE LICENSURE | OTHER | 13D0947553 | 01 | ID | CLIA WAIVER | OTHER |