Basic Information
| Provider Information | |||||||||
| NPI: | 1710296793 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN OREGON HEALTHCARE ORCHARDS RETIREMENT, L.L.C. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CASCADE VALLEY ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 NE 77TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986626729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926628 | ||||||||
| FaxNumber: | 3608825793 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 NE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | MILTON FREEWATER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978629404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419385693 | ||||||||
| FaxNumber: | 5419384490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERGREEN OREGON HEALTHCARE, L.L.C. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 1883778809 | OR | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 564166 | 05 | OR | MEDICAID |