Healthcare Provider Details

I. General information

NPI: 1043156706
Provider Name (Legal Business Name): SHALOM SD RTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 FAIRVIEW AVE
FAIRVIEW OR
97024-3761
US

IV. Provider business mailing address

1818 FAIRVIEW AVE
FAIRVIEW OR
97024-3761
US

V. Phone/Fax

Practice location:
  • Phone: 404-740-7257
  • Fax: 404-740-7257
Mailing address:
  • Phone: 404-740-7257
  • Fax: 404-740-7257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SIBAMO BETTE GAGURO
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 404-740-7257