Healthcare Provider Details

I. General information

NPI: 1134762230
Provider Name (Legal Business Name): MT HOOD HOME CARE SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 SW MAPLE ROAD
ESTACADA OR
97023
US

IV. Provider business mailing address

PO BOX 1478
SANDY OR
97055-1478
US

V. Phone/Fax

Practice location:
  • Phone: 503-826-8285
  • Fax: 971-533-7952
Mailing address:
  • Phone: 503-826-8285
  • Fax: 503-668-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNON CHRISTIE
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-826-8285