Healthcare Provider Details

I. General information

NPI: 1285631036
Provider Name (Legal Business Name): MARYVILLE NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14645 SW FARMINGTON RD
BEAVERTON OR
97007-2727
US

IV. Provider business mailing address

14645 SW FARMINGTON RD
BEAVERTON OR
97007-2727
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-8626
  • Fax: 503-520-1435
Mailing address:
  • Phone: 503-643-8626
  • Fax: 503-520-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number StateOR

VIII. Authorized Official

Name: MRS. KATHLEEN PARRY
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-643-8626