MEDICARE: SHANGRI-LA CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility		OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	516706	OTHER	OR	DMAP PROVIDER #

General Provider Information

NPI Number	:	1487908935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANGRI-LA CORPORATION

Provider Business Mailing Address
First Line	:	4080 REED RD SE STE 150
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-1335
Country	:	US
Telephone Number	:	503-581-1732
Fax Number	:	503-316-2299

Provider Business Practice Location Address
First Line	:	1206 OLD OAK DR SE
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97322-6655
Country	:	US
Telephone Number	:	541-926-8207
Fax Number	:	541-926-5781

Authorized Official
Title or Position	:	CFO
Name	:	MS. HELEN E HONEY
Credential	:
Telephone Number	:	503-581-1732

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	11/06/2012

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Directions to “SHANGRI-LA CORPORATION ” Practice Location

Language	Start Address	Practice Location

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