Healthcare Provider Details

I. General information

NPI: 1598749038
Provider Name (Legal Business Name): DALLAS MENNONITE RETIREMENT COMMUNITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 NW JASPER ST
DALLAS OR
97338-1279
US

IV. Provider business mailing address

377 NW JASPER ST
DALLAS OR
97338-1279
US

V. Phone/Fax

Practice location:
  • Phone: 503-623-5581
  • Fax: 503-623-2901
Mailing address:
  • Phone: 503-623-5581
  • Fax: 503-623-2901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number800268
License Number StateOR

VIII. Authorized Official

Name: MR. GERALD J. MCMULLIN
Title or Position: BOARD CHAIR
Credential:
Phone: 503-623-3843