Basic Information
| Provider Information | |||||||||
| NPI: | 1790909786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENCY GRESHAM NURSING & REHABILITATION CENTER LLC | ||||||||
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| OtherOrganizationName: | REGENCY GRESHAM NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3326 160TH AVE SE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980086418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253924066 | ||||||||
| FaxNumber: | 4256231517 | ||||||||
| Practice Location | |||||||||
| Address1: | 5905 SE POWELL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970801919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036651151 | ||||||||
| FaxNumber: | 5036691966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | BEDDOE | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4253924066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 808550 | OR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 800117 | 05 | OR | MEDICAID |