Basic Information
| Provider Information | |||||||||
| NPI: | 1720028509 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOUCHMARK ON SOUTH HILL LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOUCHMARK ON SOUTH HILL NURSING | ||||||||
| 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: | 5036443568 | ||||||||
| Practice Location | |||||||||
| Address1: | 2929 S WATERFORD DR | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992034400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095362929 | ||||||||
| FaxNumber: | 5035363999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRYOR | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5036465186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH1201 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 50D0917708 | 01 | OR | CLIA | OTHER |