Basic Information
Provider Information | |||||||||
NPI: | 1922352368 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHANGRI-LA CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CASA RIO | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4080 REED RD SE STE 150 | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973021335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035811732 | ||||||||
FaxNumber: | 5033162299 | ||||||||
Practice Location | |||||||||
Address1: | 4472 DEL RIO PL SE | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | OR | ||||||||
PostalCode: | 973226233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419245702 | ||||||||
FaxNumber: | 5419245703 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2012 | ||||||||
LastUpdateDate: | 08/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WINKLE | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | LENAY | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5035811732 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X |   | OR | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 519075 | 01 | OR | DMAP PROVIDER # | OTHER |